Professor Linda Bauld explains how NHS stop smoking services should be monitoring 4-week quit rates in addition to providing medication and behavioural support

Since their establishment in 1999, NHS stop smoking services have helped more than 2 million smokers in England to quit smoking.1 One in four people who successfully stop smoking each year do so with the support of these services.1 They provide one of the most effective and cost-effective interventions available on the NHS,1 and remain unique in the world—no country apart from the UK has a ‘free at the point of use’ national network for the treatment of smoking. The stop smoking services also play an important role in reducing inequalities in health. Smoking accounts for up to 50% of the difference in life expectancy between affluent and disadvantaged groups in England.2 Research has shown that NHS stop smoking services are effective in reaching and treating more deprived smokers.3

The NHS stop smoking services operate on the basis of guidance published by the Department of Health (DH), which is updated annually. The 2010/2011 version of this document is now available from the DH website.1 The best practice guidance describes how services should be commissioned and delivered. In particular, it outlines how services should aim to reach smokers, especially those from high prevalence groups, to deliver evidence-based treatment and to monitor and assess their performance.

Targeting priority groups

The NICE public health guidance on smoking cessation services, published in 2008, recommends that NHS stop smoking services should aim to reach and treat at least 5% of smokers in the local population each year.4 The services should be available, through the process of commissioning, in all primary care trusts (PCTs) and be offered to anyone who expresses an interest in quitting. These services should be commissioned on the basis of local population needs, and aim to target smokers from routine and manual occupational groups who comprise 44% of the smoking population in England.1 Commissioners need to monitor the reach and performance of services to ensure that the throughput and success rates of routine and manual smokers are at least proportionate to the local smoking population.1 Other priority groups that should be targeted include:

  • pregnant smokers
  • adults with mental health problems
  • prisoners
  • those in which smoking rates are high, such as some black and minority ethnic communities.

The DH guidance recommends that services need to be commissioned on the basis that they are accessible to smokers that have tried and failed to quit in the past.1 Most smokers have several attempts at trying to stop before achieving abstinence, and so services should encourage these individuals to return to them for more support if they do not succeed in their initial attempt.1

Access to services

Primary care
Smokers need multiple routes to access services; self referral is important but referrals should come from a range of sources to maximise reach. In particular, healthcare professionals in primary and secondary care have a key role to play in referring smokers to their local NHS stop smoking service. In primary care, GPs and other professionals such as practice and district nurses, midwives, and health visitors should identify smokers systematically, offer brief advice, and refer them to the service either through established referral pathways or appointments with a trained adviser based in a GP practice.

Secondary care
In secondary care all patients should receive brief interventions regardless of whether admission is planned or unplanned. Patients should then be referred to their local stop smoking service for more intensive support. This support can be provided initially in hospital and then should be continued following discharge.

Delivery and intervention type

Stop smoking services provide a range of interventions to help smokers quit that should be delivered on the basis of evidence5 and NICE guidance.4,6 The DH stop smoking services guidance summarises some of this key evidence.1 This includes, for example, outlining the efficacy of different models of behavioural support and interventions that are tailored at target groups of smokers. Services should offer a combination of behavioural support and stop smoking medication. This combination of treatment can be, and is delivered in a wide range of settings including community venues, primary care, secondary care, dental practices, pharmacies, prisons, and military bases.

The relative impact on 4-week quit rates of stop smoking medications with no, one-to-one, or group behavioural support is shown in Figure 1.7–11 Between 25% and 37% of smokers who use stop smoking medication but do not use NHS cessation services can be expected to stop in the short term (4 weeks).7–11 Stop smoking services should therefore be able to demonstrate success rates in excess of this, as the behavioural support and advice on medication use that they provide can significantly improve quit rates when compared with medication alone.1

The most effective combination of treatment currently delivered by services is behavioural support delivered in groups (structured-group meetings weekly for around 6 weeks) plus varenicline.1,11 Group support is almost as effective when provided with combination nicotine replacement therapy (NRT), which involves using two or more forms of NRT, such as gum and patch. It is recommended that PCTs should offer all forms of stop smoking medication as first-line treatment.1

The 4-week quit rate shows that one-to-one behavioural support (provided by telephone or in person) is generally less effective than group support,7–11 although it remains the most common form of delivery. Services have developed new forms of intervention including:

  • drop-in clinics
  • support for couples or families rather than an individual smoker
  • groups that run on an open rolling basis (where smokers can attend at any stage in their quit attempt).

The above forms of delivery are popular with clients, but to date there is no conclusive evidence regarding their efficacy.1,12

Figure 1: Effectiveness of pharmacotherapy and support options on 4-week quit rates7-11
figure 1
4-week quit rates No medication
(%)
Single NRT
(%)
Combination NRT (%) Bupropion
(%)
Varenicline
(%)
No support 16 25 36 28 37
Individual behavioural support 22 37 50 39 52
Group behavioural support 32 50 71 55 74
NRT=nicotine replacement therapy
Reproduced with permission from Department of Health

Monitoring quit rates

All NHS stop smoking services are required to collect data from every client using a core set of questions outlined in the gold standard monitoring form included in the DH guidance.1 Services may choose to add additional questions to inform developments at the local level or for the purposes of research. The core questions cover socio-demographic details, type of intervention offered, and stop smoking medication received by the client. Data are collected from all individuals who set a quit date with the service. The outcome of the client’s quit attempt is recorded 4 weeks after the quit date. At this point, smoking status should be validated by a carbon monoxide (CO) test. The DH guidance recommends that services validate a minimum of 85% of all 4-week quitters.1

Primary care trusts return data on client monitoring electronically to the NHS Information Centre. These include quit rates that are calculated on the basis of the number of treated smokers who report abstinence from day 14 post-quit to the 4-week follow up as a proportion of all smokers who set a quit date with the service. An exception-reporting procedure is now in place (see Figure 2,) to investigate outlying data that fall outside of the recommended range of 4-week quit rates (i.e. between 35% and 70%). The steps specified in the procedure should be followed if results for the service as a whole or for a particular intervention type or setting fall outside this range.1

Smoking cessation targets
The results of stop smoking service monitoring are reported through stop smoking service statistical bulletins published on the Information Centre website.13 The data also provide a valuable tool to inform commissioning and measure performance. Each PCT has a local smoking cessation target that stipulates the number of 4-week quitters that they should achieve per year. These targets have been challenging for services and placed undue emphasis on maximising throughput at the expense of quality. It is now recognised that these 4-week quit targets should not be the sole measure of tobacco control outcomes, which would be better served by prevalence-based indicators. This is under consideration as part of the new 10-year National strategy for tobacco due to be published by the DH in December 2009.

Figure 2: The exception-reporting procedure1
figure 2
PCT=primary care trust; SHA=strategic health authority
Reproduced with permission from the Department of Health

Conclusion

Although stop smoking services have an important role to play in reducing smoking prevalence, wider tobacco control measures (such as smoke-free environments and measures to reduce the availability of tobacco) are also essential. Efforts to emphasise the importance of quality in delivery have also been aided by the establishment of the new NHS Centre for Smoking Cessation and Training (NCSCT).14 The NCSCT will coordinate and improve upon existing training for stop smoking advisers and is also developing national training standards that will be available by March 2010. These developments should provide NHS stop smoking services with improved capacity to support many smokers to quit in the future.

Useful websites

Acknowledgements

The 2010/2011 NHS stop smoking service monitoring guidance was produced by the Department of Health with assistance from a guidance working group. The author would like to give particular thanks to Dr Paul Aveyard who reviewed the evidence on the effectiveness of pharmacotherapy and behavioural support for the guidance.

  • Smoking cessation services should be actively commissioned by local PBC groups
  • The commissioning plan should be informed by public health information to target individuals who are the most frequent smokers and those who may be harder to reach
  • A range of services should be commissioned to meet local needs
  • Commissioners should be increasing their focus on stipulating expected outcomes from smoking cessation services and incentivising these
  • Commissioners could build on the national program and consider extra targets for their locality (e.g. 6-month quit rates)
  • PBC groups will need to identify the potential increased costs of nicotine replacement therapies and other smoking cessation medication in their PBC budgets—any savings on other budgets will be longer term
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    2. Jha P, Peto R, Zatonski W. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. Lancet 2006; 386 (9533): 367–379.
    3. Bauld L, Judge K, Platt S. Assessing the impact of smoking cessation services on reducing health inequalities in England: observational study. Tobacco Control 2007; 16 (6): 400–404.
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    13. The Information Centre. NHS stop smoking services. www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/nhs-stop-smoking-services (accessed 12 November 2009).
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