Norwich Medical SchoolFaculty of Medicine and Health Science

Longer-Term Smoking Abstinence after treatment by specialist or non-specialist advisors:

secondary analysis of data from a trial

Song F1 Maskrey V1 Blyth A1 Brown TJ1

Barton GR1 Aveyard P2 Notley C1 Holland R1

Bachmann MO1 Sutton S3 Brandon TH4

1. Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK 2. Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK 3. Institute of Public Health, University of Cambridge, Cambridge, UK 4. Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa FL, USA

Introduction

• Behavioural and pharmacological interventions are cost-effective

for smoking cessation.

• In English stop smoking services, smokers motivated to quit may

receive support in specialist clinics (33%), primary care (39%),

pharmacy (21%), or other settings (7%). [Data in 2012/13]

• Previous studies found that smokers treated in specialist centres

tend to have a higher short-term quit rate, compared with those in

non-specialist settings (by professionals for whom smoking cessation is only

a part of their work).

Objectives

• To investigate differences in longer-term abstinence

between short-term quitters who received smoking

cessation treatment in specialist or other settings

• A secondary analysis using data from a relapse

prevention trial

SHARPISH: randomised controlled trial of self-help booklets for smoking relapse prevention

• Funded by NIHR/HTA programme (09/91/36), to investigate the effect of self-help materials for the prevention of smoking relapse in 4-wk quitters who have used NHS Stop Smoking Services.

Experimental:8 Forever Free booklets (version for the UK patients)

Control: Learning to Stay Stopped leaflet

Main findings: No difference between the intervention groups in smoking abstinence from 4 to 12 months (37% vs. 39%; P=0.51)

Methods

• Data from SHAPRISH trial: 1088 short-term quitters from specialist

centres, 220 from general practice, 57 from health trainers, and 39

from pharmacy.

• Primary outcome: prolonged abstinence from months 4 to 12, with ≤5

cigarettes in total, and confirmed by CO<10ppm at 12 month.

Participants who declined CO test were classified as relapse.

• The difference in longer-term smoking abstinence between specialist

and non-specialist services was compared, using multivariable logistic

regression analysis, adjusted for possible confounding factors.

Comparability of main characteristics at baseline between services

Baseline variable Specialist services

(N=1088) Non-specialist

(N=316) P value

Age: mean (SD) 48.1 (13.9) 47.0 (13.2) 0.18

Female 52.4% (570) 53.8% (170) 0.66

Ethnicity –white 98.6% (1070) 98.7% (312) 0.88

Married/living with a partner 62.6% (680) 58.5% (185) 0.19

Education up to GCSE 54.9% (590/1074) 54.5% (170.312) 0.48

Unemployed 10.5% (114) 8.5% (27) 0.14

Receipt of free prescription 58.0% (625/1077) 53.5% (165/310) 0.13

Any previous quit attempts 88.6% (963/1087) 91.1% (288/316) 0.20

<10 cig/day before quitting 13.5% (147/1087) 15.8% (50/316) 0.30

1st cig. <5 minutes after waking 42.9% (466/1087) 39.9% (126/316) 0.34

Living with a smoking partner 18.2% (198) 19.0% (60) 0.75

Use of smoking cessation medications during 2-3 months after the quit date

Any SC medication % (n)

Any NRT % (n)

Varenicline % (n)

Total N

Specialist services 74.6% (812) 36.3% (395) 40.6% (442) 1088

All non-specialist 72.5% (229) 36.4% (115) 36.4% (115) 316 - General practice 74.6% (164) 30.9% (68) 44.6% (98) 220

- Health trainer services

70.2% (40) 40.4% (23) 29.8% (17) 57

- Pharmacy 64.1% (25) 61.5% (24) 0% (0) 39

Total 74.2% (1041) 36.3% (510) 39.7% (557) 1404 Specialist services vs. all non-specialist services Pearson χ2 test: P=0.439 P=0.977 P=0.176

Across different settings (specialist, GP, health trainer, and pharmacy) Pearson χ2 test: P=0.445 P=0.003 P<0.001

Prolonged abstinence from months 4-12 in short-term quitters by type of advisors

39%

34%

28%

28%

0% 10% 20% 30% 40% 50%

Specialist service(n=1088)

GP Practice(n=220)

Pharmacy(n=39)

Health Trainer(n=57)

Abstinence rate (95% CI)

Results of multivariable logistic regression analysis for prolonged smoking abstinence from 4-12 month

Odds ratio (95% CI) P value

Specialist vs. non-specialist services 1.477 (1.092, 1.997) 0.011

Age (year) 1.013 (1.002, 1.023) 0.016

Female vs. male 0.933 (0.723, 1.205) 0.596

Married or living with a partner 1.520 (1.158, 1.995) 0.003

Low education (up to GCSE) 0.940 (0.726, 1.218) 0.641

Unemployed 0.634 (0.398, 1.012) 0.056

Free prescription 0.898 (0.675, 1.195) 0.461

Any previous quit attempts 0.702 (0.439, 1.123) 0.140

>4 weeks managed to quit before 1.770 (1.245, 2.517) 0.001

<10 cigarettes/day before quitting 0.785 (0.605, 1.018) 0.068

1st cigarette within 5min after waking 0.817 (0.586, 1.140) 0.235

Living with a smoking partner 0.888 (0.639, 1.236) 0.480

Use of NRT therapy during 2-3 months 1.652 (1.214, 2.248) 0.001

Use of varenicline during 2-3 months 1.335 (0.987, 1.805) 0.060

Discussion

• Possible reasons for varying longer-term abstinence in

short-term quitters by different types of advisors:

-Training and supervision received

-Adherence to evidence-based practice

-Group-based vs. individual sessions

-Intensity of support

-Confounding factors

Implications

• Assuming the same quit rate (37%) at 4 weeks after the quit date,

the prolonged abstinence rate from 4-12 months in people who set

a quit date will be 14.4% and 11.8% respectively, with a difference

of 2.6% between specialist and non-specialist services.

• The total number of people who set a quit date in non-specialist

services was 485,245 in 2012/13 in England 3. If the rate of

prolonged abstinence was increased by 2.6%, there would be

12,616 more people who were abstinent at 12 months.

Main limitations

• A secondary analysis of data from a trial (not

randomised)

• More short-term quitters from specialist services, and

fewer from non-specialist settings

• A comparison between different non-specialist

settings was not conducted due to inadequate sample

size

Conclusions

• Although smoking cessation support in any setting is cost-effective,

specialist counselling, as an intervention that improves longer-term

outcomes, should be emphasised.

• Health care professionals who provide smoking cessation

counselling in non-specialist settings should receive more training

and supervision.

• Further research is needed to investigate reasons for the

difference in longer term outcomes, and whether enhancing

training and skills in non-specialist advisors can reduce longer term

relapse.

Main references • Blyth A, Maskrey V, Notley C, et al. Self-help educational materials for the prevention of

smoking relapse: randomised controlled trial (SHARPISH). Health Technology Assessment 2015. (Forthcoming).

• McDermott MS, Beard E, Brose LS, West R, McEwen A. Factors associated with differences in quit rates between "specialist" and "community" stop-smoking practitioners in the English stop-smoking services. Nicotine Tob Res. 2013; 15:1239-1247.

• McEwen A, West R, McRobbie H. Effectiveness of specialist group treatment for smoking cessation vs. one-to-one treatment in primary care. Addictive behaviors. 2006; 31:1650-1660.

• McDermott MS, West R, Brose LS, McEwen A. Self-reported practices, attitudes and levels of training of practitioners in the English NHS Stop Smoking Services. Addictive behaviors. 2012; 37:498-506.

• Brose LS, West R, Michie S, McEwen A. Changes in success rates of smoking cessation treatment associated with take up of a national evidence based training programme. Prev Med. 2014; 69C:1-4.

• Bauld L, Boyd KA, Briggs AH, et al. One-year outcomes and a cost-effectiveness analysis for smokers accessing group-based and pharmacy-led cessation services. Nicotine Tob Res. 2011; 13:135-145.

Acknowledgements• This project was funded by the NIHR HTA programme (Project 09/91/36). The views and

opinions expressed therein are those of the authors and do not necessarily reflect those of

the Department of Health.

• We thank stop smoking advisors from NHS stop smoking services in Norfolk, Lincolnshire,

Suffolk, Hertfordshire, Great Yarmouth and Waveney for recruiting quitters to the study. The

trial was conducted in collaboration with the Norwich Clinical Trials Unit whose staff

provided input into the design, conduct and analysis (Tony Dyer – randomisation and data

management). We thank Laura Vincent for providing administrative support, data entering

and data checking.

• Declaration of interest: PA has done ad hoc consultancy and research for the

pharmaceutical industry on smoking cessation. THB has received research funding and

study medication from Pfizer, Inc. No other competing interest declared; no other

relationships or activities that could appear to have influenced the submitted work.