1. 1 A national initiative to help smokers quit: the English experience Robert West University College London Stockholm, April 2008

2. Statement of competing interest I undertake research and consultancy for companies that develop and manufacture smoking cessation medications I have a share of a patent for a novel nicotine delivery device I undertake training in behavioural support for smoking cessation

3. Outline Rationale Smoking cessation guidelines Brief advice from a health professional NHS stop smoking services NRT over the counter Current issues

4. Rationale Acceptance that: –cigarette addiction is a treatable disorder that has life-threatening consequences –that treatments are highly cost-effective as a way of saving lives –these treatments include all licensed Nicotine Replacement Therapies bupropion varenicline behavioural support provided one-to-one or in groups –the optimal treatment programme is behavioural support plus medication –all healthcare professionals have a role in encouraging cessation

5. The 1998 Thorax Guidelines Raw, McNeill & West: –established the principle of the effectiveness and cost effectiveness of treatments for cigarette addiction –made recommendations for: the delivery of treatment programmes involving setting up the NHS Stop Smoking Services brief opportunistic advice from physicians to stop together with: –recommendation to use SSS –prescription for NRT

6. The 2000 Thorax Guidelines West, McNeill & Raw: –updated the evidence base on treatment for cigarette addiction –made recommendations for: the delivery of specialist treatment programmes by the NHS Stop Smoking Services brief opportunistic advice from physicians to stop together with: –recommendation to use SSS –prescription for NRT and bupropion

7. 2001 NICE guidance on Zyban and NRT undertook new reviews and confirmed the cost- effectiveness of Zyban and NRT recommended prescribing paid for by the National Health Service

8. 2006 NICE guidance on brief interventions undertook new reviews and confirmed the cost- effectiveness of brief physician advice emphasised importance of referral to stop smoking services

9. 2007 NICE guidance on varenicline undertook full meta-analysis recommended that varenicline should be offered as first line treatment stated that it is more effective than bupropion and NRT

10. 2008 NICE guidance on stop smoking services undertook new reviews and examined the NHS Stop Smoking Services and other treatment programmes –Confirmed the cost effectiveness of the NHS Stop Smoking Services –Recommended specialist support –Confirmed cost-effectiveness of medications –Recommended use of a minimum training standard for staff delivering behavioural support

11. Brief physician advice General practitioners are: –paid extra to raise the issue of smoking during routine consultations and give brief advice to stop and –encouraged to refer smokers to the stop smoking services and/or to prescribe medication to aid cessation In practice: –General practitioners report high rates of giving advice –Many general practitioners never refer to NHS services –Some general practitioners refuse to prescribe medications to aid cessation

12. Stop Smoking Services Treatment to aid smoking cessation is integrated into the National Health Service, paid for out of national taxes There is an extensive network of smoking cessation services organised at the level of Primary Care Trusts covering an average of 200,000 adults (50,000 smokers)

13. England: No. Treated & 4 Week Quitters CO-verified 4-week quitters: 33% Slide from Gay Sutherland, Kings College London

14. 4 Week Quitters/100K Pop. England (2006-07) Slide from Gay Sutherland, Kings College London

15. England: Cost (£) Per Self-Report 4 Wk Quitter (Excluding Medication) Slide from Gay Sutherland, Kings College London

16. England: Use of Medications (%) Q1: 2007-08 April-June Slide from Gay Sutherland, Kings College London

17. NRT = 1,938,000 Zyban = 119,000 Net Ingredient Cost (NIC): NRT = ~ £39.5 million Zyban = ~ £4.3 million NIC Cost does not take account of discounts, dispensing costs, fees or prescription charge income Number of prescriptions (2006-2007) Slide from Gay Sutherland, Kings College London

18. English Quit Rates (%) by Medication (Self Report) 2007-08 April-June Slide from Gay Sutherland, Kings College London

19. NRT bought over the counter The national regulatory body has allowed NRT to be made available for sale over the counter in any store The government has reduced VAT on NRT to 5% 35% of quit attempts involve use of NRT bought over the counter

20. Current issues There is wide variation in the reported throughput and success rates of different stop smoking services There has been a drive to increase numbers of smokers attending which may be driving down quality Stop smoking services are adopting innovatory methods that are not necessarily evidence-based: –rolling groups where smokers join at any time –drop-in clinics where smokers attend without appointment Stop smoking specialists receive varying amounts of training and supervision and do not have to pass a competency test

21. The future It is likely that the stop smoking services will be more heavily promoted, particularly targeting low income smokers New guidance should improve the quality of delivery and reporting Varenicline has improved success rates and use will probably be expanded

22. Conclusions The English stop smoking services were set up on the basis that if there is a proven life-saving medical treatment that is cost-effective, it should be provided by the National Health Service The service has developed and expanded over that past 8 years and treats half-a million smokers each year Report success rates are high but variable More needs to be done to determine and disseminate best practice across the services