Smoking Cessation Treatment Services in the United Kingdom Hayden McRobbie Barts and The London School of Medicine University of London

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

Adult smoking prevalence, UK MenWomen %

National Health Service Government funded through taxation Government 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, community care, medication Hospital treatment, family doctors, community care, medication Devolved to local level Devolved to local level Initially 100 Health Authorities, now 300 Primary Care Trusts (PCT) Initially 100 Health Authorities, now 300 Primary Care Trusts (PCT) Each PCT has its own smoking cessation service Each PCT has its own smoking cessation service

New Government Strategy Smoking Kills ( 1998)

Response to the White Paper 3 years of ring fenced funding for Health Authorities: 3 years of ring fenced funding for Health Authorities: year 1 for Health Action Zones ($16 million) year 1 for Health Action Zones ($16 million) years 2 and 3 nationwide ($32 million) years 2 and 3 nationwide ($32 million) Professionally endorsed national smoking cessation guidelines Professionally endorsed national smoking cessation guidelines

Structure of services Healthcare staff: GPs Hospital doctors Dentists Nurses etc. Core clinic Community specialists Co-ordinator Referral Training Wide reach Robust service Expertise enhanced Management

Training Only short courses so far Only short courses so far The longest established is the “Maudsley Model” (SCTRP) course for specialists (intensive 3 day evidence based training, with annual updates) The longest established is the “Maudsley Model” (SCTRP) course for specialists (intensive 3 day evidence based training, with annual updates) Other courses based on stages of change and motivational interviewing for community advisors Other courses based on stages of change and motivational interviewing for community advisors ‘In-House’ training – variable quality (0.5-1 day) ‘In-House’ training – variable quality (0.5-1 day) Heath Development Agency Training Standards Heath Development Agency Training Standardswww.hda.nhs.uk/documents/smoking_cessation_treatments.pdf

Treatment Evidence based – following national guidelines Evidence based – following national guidelines Combination of behavioural support and pharmacotherapy Combination of behavioural support and pharmacotherapy Withdrawal oriented treatment used for core clinics (Hajek 1989) Withdrawal oriented treatment used for core clinics (Hajek 1989) 6 or 7 weekly treatment sessions (predominantly group setting, but individual sessions used where appropriate) 6 or 7 weekly treatment sessions (predominantly group setting, but individual sessions used where appropriate) Assist smokers to avoid early relapse Assist smokers to avoid early relapse Emphasis on complete abstinence, supervision of medication use, motivational support Emphasis on complete abstinence, supervision of medication use, motivational support

Evaluation Monitored Monitored Staffing and costs Staffing and costs Throughput Throughput 4-week success rates 4-week success rates Targets Targets Throughput Throughput Success rates Success rates League tables published League 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

NHSSmoking Cessation Services NHS Smoking Cessation Services THE RESULTS

The GOOD: Success!

Performance of the services Nationally, group treatment is a positive predictor of 4-week abstinence ( Bauld, Chesterman, Judge et al. Tobacco Control 2003; 12: ) Nationally, group treatment is a positive predictor of 4-week abstinence ( Bauld, Chesterman, Judge et al. Tobacco Control 2003; 12: ) Within local services, where comparison is possible, the core clinic produces higher abstinence rates than community advisors e.g. clinic 58% vs. community 39%, (Turbitt, Smoking Cessation Services in East London, 2003) Within local services, where comparison is possible, the core clinic produces higher abstinence rates than community advisors e.g. clinic 58% vs. community 39%, (Turbitt, Smoking Cessation Services in East London, 2003)

The BAD: Problems Demands on newly developed services Demands on newly developed services Many services moved away from evidence base Many services moved away from evidence base Medications: Limited NRT supply initially & most services unable to prescribe Medications: Limited NRT supply initially & most services unable to prescribe Funding: drip-fed initially; no longer ring-fenced Funding: drip-fed initially; no longer ring-fenced Staff: shortage & uncertain career development Staff: shortage & uncertain career development NHS organisation changes NHS organisation changes not so ^

The UGLY: Targets No. of 4 Week Quitters

Targets for London!

Conclusions Smoking cessation services are now established Smoking cessation services are now established National guidelines, national training standards, and services offering evidence based treatment National guidelines, national training standards, and services offering evidence based treatment UK has a new group of professionals – approximately 1,000 full-time smoking cessation specialists UK has a new group of professionals – approximately 1,000 full-time smoking cessation 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 far, e.g. pitfalls of mixing health promotion and clinical treatment Lessons can be learnt from our experience so far, e.g. pitfalls of mixing health promotion and clinical treatment Challenges for the future, but hopefully services will continue to develop to meet the needs of smokers who want to quit Challenges for the future, but hopefully services will continue to develop to meet the needs of smokers who want to quit

Pohutukawa – New Zealand Christmas Tree