1. Noel Baxter and Louise Restrick Stop smoking as treatment workstream 2010-2013 Stop Smoking as Treatment

2. COPD in London: What do we know? COPD Mortality

3. COPD in London: What do we know?

4. Londoners dying from smoking ‘1 in 5 deaths due to smoking ’

5. Is current smoking an issue in COPD? TORCH, Uplift and POET-COPD Studies

6. Is current smoking an issue in COPD? 2010 ERS Audit

7. NEJM 3: 2012

8. What is the prevalence of smoking in London in people with COPD?

9. So do we know what the extent of the problem is? …Yes in Tower Hamlets 40%

10. And in Southwark in 2013 Prevalence of current smoking where status recorded in last 15 months 1550/3335 = 46.5% COPD smokers in last year receiving evidence based stop smoking support – 17.5%

11. Fletcher and Peto British Medical Journal 1977 What treatment reduces lung decline in COPD?

12. Randomised Clinical Trial 5887 people with airway obstruction over 14.5 years Effect of Smoking Cessation Intervention on Mortality in COPD Anthonisen NR, Skeans MA, Wise RA; Manfreda J, Kanner RE & Connett JE for the Lung Health Study Research Group* Ann Intern Med. 2005;142:233-239.

13. 1 year abstinence % QALY £ Usual care1.4 Minimal counselling2.614,735 Intensive counselling67,149 Intensive counselling + pharmacotherapy 12.32,092 Systematic Review of 9 studies Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH. Thorax 2010: 65:711-718 What treatment for COPD is highly cost effective the more you do?

14. We know what stop smoking interventions are good value – when they are done in the right way

15. This is how it really looks and hospital providers !

16. Its not just COPD but COPD is a good marker for sick smokers?

17. Do we have a blind spot for sick smoker treatment opportunities? We need to change how we think about smoking

19. Changing how we think about smoking Supporting smokers who have COPD (or asthma or….) is their number one TREATMENT Sick smokers are admitted to hospital Smoking is tobacco addiction Evidence based quit smoking treatment is the most important treatment for sick smokers: Behaviour change support and quit smoking medication ‘Smoking kills, stopping works’ Sir Richard Peto 2012

20. Is Very Brief Advice happening for every smoker? Online training module WWW.NCSCT.CO.UK/VBA ‘This training is relevant to anyone who comes into contact with smokers… GPs, practice nurses, hospital doctors, pharmacists & other healthcare professionals. … certificate on successful completion to provide evidence of continuing professional development (CPD).’ Do you have and use or commission behaviour change skills to support smokers to stop?

21. Are your staff able, & confident to, prescribe Quit Smoking medication? Does your hospital provide nicotine replacement therapy routinely on admission for smokers?

22. Tashkin et al, Chest 2011: 139:591-599 Mean age 57 years Mean FEV1 2.3 L (70% predicted) 40 pack-years High nicotine dependence 80% previous serious quit attempt Varenincline and support

23. Jiminez Ruiz et al Nicotine and Tobacco Research 2011 ~500 smokers with severe COPD Mean age 58 years 60 pack-years of smoking High nicotine dependence 10 intensive behavioral interventions with medication: 233 Nicotine Replacement Therapy & 190 Varenicline 48.5% abstinence at 6 months 61% with Varenicline and 44% with NRT Safe Even those with severe disease

24. Even before that paper we knew enough to proceed at a clinical level ‘Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates… to all people with COPD who still smoke at every opportunity.’ NICE 2010

25. Varenicline  4  2 neuronal nicotinic acetylcholine receptor partial agonist Reduces craving Reduces withdrawal Reduces pleasure of smoking (prevents binding) Costs £2 /day; £60/month12 week course ~ £160 … may need 24 weeks in COPD 7 days treatment July 2012 Cheaper than ‘triple therapy’ (inhalers!) and … higher value

26. Where are the people? Sick smokers in hospital beds Smokers in mental health services In prisons Quietly stoical at home Multiple prescriptions

27. Interventions based on local knowledge http://www.londonhp.nhs.uk/wp- content/uploads/2011/06/COPD- profile-Bromley.pdf

28. Are people with mental health problems getting the treatment they need? Himelhoch S, Lehman A, Kreyenbuhl J et al. Am J Psychiatry 2004;161:2317-2319 0 200 out-patients with SMI 60% current smokers (mean age 44) 23% COPD prevalence (self-reported) Only 36% reported having COPD treatment 147 Medicaid patients with SMI 31% COPD prevalence; 50% as co-morbidity Annual costs for SMI and COPD were 4 x higher 45% (5/11) deaths due to respiratory disease Jones DR, Macias C, Barreira PJ et al Psychiatric Services 2004;55:1250-1257

29. Smoking prevalence & tobacco dependence in people with mental illnesses % Adults 21% smokers 9% heavy smokers Inpatients with serious mental illness People living with mental illnesses O’Brien et al 2002, Farrell et al 2001 (>20 cigarettes/day) 50% of smokers heavy smokers 30% of smokers heavy smokers High prevalence of severe tobacco dependence Very high smoking prevalence Just like our smokers with COPD …

30. COPD, smoking and outcomes for people with mental illness ‘People with mental health problems … die on average 16-25 years sooner than the general population. … have higher rates of respiratory, cardiovascular & infectious disease...’ ‘Increased smoking is responsible for most of the excess mortality of people with severe mental health problems. Adults with mental health problems …. smoke 42%* of all tobacco in England. * not including mental health settings, prisons, homeless or temp housing Very high prevalence of cannabis smoking too

31. Do people with mental illnesses get the right COPD treatment? Population5 year COPD mortality Schizophrenia28% Bipolar disease19% Age adjusted population12% Five year mortality for respiratory disease much higher in people with mental illness At least 1 in 4 deaths in people with mental illnesses due to respiratory disease Hippisley-Cox J et al. Health outcomes for patients with serious mental health problems: 2 nd report to the DRC 2006 Joukamaa et al British Journal of Psychiatry 2006:188;122-127, Jones D et al Psychiatric Services 2004;55:1250-1257 www.rcpsych.ac.uk/pdf/No%20Health%20-%20%20the%20evidence_%20revised%20May%2010.pdf

32. 2004 …in people living in mental health institutions > 40% prevalence > 70% prevalence Smoking prevalence …in people with mental illnesses

33. Do people with mental illnesses want to stop smoking? Clearing the Air. King’s Fund 2006 70% of smokers want to stop >50% of smokers with mental illness also want to stop YES

34. Do quit smoking interventions work for people with mental illnesses? Addiction 2010;105:1176-118 2011 YES Cost-effectiveness studies?

35. Do we support people with mental illnesses to stop smoking (in London)? Data courtesy of Dr Lisa McNally, NHS Surrey and Lead Smoke Free Minds

36. Changing how we think about smoking in mental health settings? Treating tobacco dependence is effective in SMI Same treatments work as for anyone else Treatment does NOT worsen mental state Banham L, Gilbody S. Addiction 2010;105:1176-118 ‘Attitudes and therapeutic actions of mental health professionals must also be taken into consideration…’

37. ‘Some practitioners expressed doubt about the value of smoking cessation advice for people with mental health conditions’. Do mental health care professionals believe this? ‘Unfortunately, no ready-made interventions exist to address this problem, because tobacco addiction has an illness-related aetiology and smoking cessation may elevate psychiatric symptoms.’ The case for change … Jones et al. Psychiatric Services 2004

38. Getting COPD Care and stop smoking interventions right for people with mental illnesses Mental Health Services Respiratory & GP Services Druug Dependency Services Stop Smoking Services

39. Getting COPD Care and stop smoking interventions right for people with mental illnesses Respiratory Physician Respiratory Nurse Specialist Mental Health Key Worker Quit Smoking Advisor

40. So if we dealt with smoking in physical and mental illness patients would it tackle…. Premature mortality Optimising bed days Waste – human spirit, staff resources, time, prescriptions

41. 5% of the NHS 'smoking' budget is currently spent on quit smoking support … What does smoking cost? £2.7 billion a year spent on treating smoking related illness ‘ … less than £150 million spent on smoking cessation …’

42. Why does COPD matter? Costs to patients Costs to health service It can be treated Treatment alters outcomes

43. We know how to allocate resource at population level http://www.impressresp.com/index.php?option=c om_content&view=article&id=167:impressions-28- relative-value-of-copd- interventions&catid=11:impressions&Itemid=3

44. Effect of smoking on hospital admissions for COPD For every 1% increase in prevalence of smoking in your COPD population there is a 1% increase in COPD admission rates.

45. Do you as a commissioner believe that Quit Smoking treatment is high value for patients and staff? Do you as a hospital decision maker believe that Quit Smoking treatment is high value for patients and staff? Do you as a health professional believe that Quit Smoking treatment is high value for your patient?

46. Primary care management of tobacco dependence and long term conditions, ongoing, sustained, LES, QOF Supporting sick smokers: CQUIN, NRT, stop smoking champions Fall in children's asthma admissions equivalent to 6802 fewer hospital admissions in 3 years after smoking ban.http://pediatrics.aappublications. org/content/earl y/2013/01/15/pe ds.2012- 2592.abstract …http://pediatrics.aappublications. org/content/earl y/2013/01/15/pe ds.2012- 2592.abstract … http://jpubhealth.oxfordjou rnals.org/content/34/1/37.l onghttp://jpubhealth.oxfordjou rnals.org/content/34/1/37.l ong 200 public health interventions analysed for cost-effectiveness 15% were cost -saving 85% were under 20k per QALY Its not just about prevention…. Where does the clinical commissioner come in?

47. Does your hospital have incentives for Quit Smoking as treatment?

48. Different tariffs for different problems 2013-14 (* non- mandatory) 1 st single 1 st multi FU single FU multiNon face to face* SpellTrim- point (days) Respiratory medicine OP 18924510414523 COPD or bronchitis with NIV without intubation with CC emergency admission 277124 Stop smoking West Midlands (2012- 13*) General pop’n no Rx Target ed pop’n no Rx General pop’n with Rx Targeted pop’n with Rx (4 week quitter94136166214) 12 week quitter – verified in primary care 129271228427

49. A full complement of NICE-recommended pharmacotherapy’s A fulltime stop smoking specialist (Band 7 or above) with further trained dedicated stop smoking staff A robust data collection and referral system with linkage to other providers Stop smoking clinics led by clinical specialists A mandatory training program for all health professionals Mandatory recording of smoking status, stop smoking interventions on discharge summaries and inclusion of smoking on death certificates for patients where smoking contributed to long term illness and/or directly to death Clinician led hospital or other provider stop smoking steering group What commissioning for sick smokers could provide

50. Do you have a Quit Smoking service for patients and staff in your service? Do your staff know your Quit Smoking advisors and refer to your Service? Does your hospital have a BTS Quit Smoking Champion lead (/consultant Quit Smoking clinical lead)? Services Offered: Outpatient Quit Smoking Clinics: for patients and staff Inpatient Assessment for Quit Smoking Support Special Clinics – Pre-operative Assessment & Maternity Support for smokers to quit

51. Smokers n=16 Smokers on Respiratory Ward n=9 Smokers on other Wards n=7 Offered NRT NRT prescribed SCS offered SCS referral made ERS Audit 2010 Are we supporting sick smokers with COPD to stop during hospital admission?

52. Smokers n=16 Smokers on Respiratory Ward n=9 Smokers on other Wards n=7 Offered NRT 12 (75%) NRT prescribed 8 (50%) SCS offered 11 (69%) SCS referral made 7 (44%) ERS Audit 2010 Are we supporting sick smokers with COPD to stop during hospital admission?

53. Smokers n=16 Smokers on Respiratory Ward n=9 Smokers on other Wards n=7 Offered NRT 12 (75%) 9/93/7 NRT prescribed 8 (50%) 6/92/7 SCS offered 11 (69%) 7/94/7 SCS referral made 7 (44%) 4/93/7 ERS Audit 2010 Are we supporting sick smokers with COPD to stop during hospital admission?

54. What should we do for sick smokers during hospital admission? NEJM 3: 2012

55. How important is it to you to stop smoking? On a scale of 0-10 where 0 is not at all important and 10 is very important.’ Using Motivational Interviewing with tobacco dependent smokers with COPD ‘20/4/2012 9/10 importance and 6/10 confidence’ ‘How confident are you that you can stop smoking? On a scale of 0-10 where 0 is not confident at all and 10 is completely confident.’

56. Building a Quit Smoking as Treatment Service Respiratory clinical leadership > 10 years BTS Quit smoking champion > 5 years Quit smoking advisor in hospital > 5 years Smoking addressed on post-take ward rounds > 5 years NRT ‘offered’ to all smokers admitted ~ 5 years NRT available on all medical wards ~ 3 years