Secondary care and smokingservices in Wales

Dr Keir E Lewis

Reader in Respiratory Medicine & Consultant Chest Physician

Declaration of interests

Research grants: Pfizer (£135,000), Glaxo-Smith Kline (£9,000),

Cardiff University (£2000)

Conference attendance and honoraria for lectures and advisory

boards: GSK, Pfizerboards: GSK, Pfizer

Smoking cessation specialist HDd HB: Pfizer (£5900)

(Honorary) Trustee for ASH Wales

It is the imperative of every lover of mankind, to unite in suitable

efforts to remove this rapidly increasing evil . . . and its enslaving

power on the habits . . .and also, by seeking to deter others,

especially the young, from acquiring this unnecessary, offensive and

injurious practice.

6th Principle British Anti-Tobacco Society, 1853.

Identifying the need - Political

• ‘ . . smoking is the greatest single cause of preventable

illness and premature death in the UK . .’

Govt White Paper 1988

• NHS Smoke Free 2007• NHS Smoke Free 2007

• Wales Tobacco Action Plan 2012-

• Presentation to Health Minister

• Health Board’s Smoking Policy

Triggers for most recent quit attempt

Seeing a health warning on a cigarette packet

Being contacted by my local NHS Stop Smoking Services

Health problems I had at the time

A concern about future health problems

Attending a local stop smoking activity or event

Something said by family/friends/children

A significant birthday

5

0 5 10 15 20 25 30

Advice from a GP/health professional

TV advert for a nicotine replacement product

Government TV/radio/press advert

Hearing about a new stop smoking treatment

A decision that smoking was too expensive

Being faced with smoking restrictions

I knew someone else who was stopping

Seeing a health warning on a cigarette packet

%

Data from 1237 smokers who tried to quit in past year, surveyed May 2009 onwards; smokerscould select more than one item

Percentage of smokers using different routes toquit

15%2%

No aid

NRT over-the-counter

6

52%

31%

counterMedication Rx

NHS support

N=7,808

South Wales Echo, 6 January 2003

Not all smokers are created equal!

Hospitalised smokers often:

-Older

-More addicted (e.g. higher Fagerstrom scores)

-Are already unwell

-Have multiple illnesses

-Are on multiple drugs (potential for interactions)

Rigotti NA et al. ( 2007 ). Interventions forsmoking cessation in hospitalised patients .CochraneDatabase of Systematic Reviews , 3 ,CD001837

but hospitalised patients…

•More open to help at a time of perceived vulnerability

•Teachable moments

•Place where smoking is restricted anyway•Place where smoking is restricted anyway

•Pharmacological aids (should be) readily available

• At least 33 well-designed trials

Cochrane Review updated 2008

Identifying the need - Patients

• A secondary care service is VERY cost effective

• £426 per LYG1

• 26% adults in Hywel Dda smoke

• 246 COPD admissions (current smokers 63% more likely > 3 adms/yr2)

• < 10% smokers in chest clinic prefer a community service3

• Surgical benefits (complications, repeat surgery, LOS 2 days longer)

• Cardiac procedures etc . .1 JR Soc Health 1998; 118(6),2. Garcia-Aymerich 2003

3. Thorax 2005; 60 (ii): 37)

Inpatients:

80 % of smokers attending MAU would like to receive some

counselling during admission4

Outpatients:

Where do patients prefer a stop smoking service to belocated?

Outpatients:

65% of smokers attending Chest Clinics would prefer their

SSS to based wholly or partly in Secondary Care5

4. Murphy J, Williams A [Unpublished]5. Thorax 2005; 60(s) ii37: S105

NICE Technical Appraisal No. 38, 7.3, 2003

‘‘ Arrangements should be made to

ensure that smoking cessation advice

and support is available to patients at

both community and hospital locations. ’’

www.nice.org

Only 4 from 17 Welsh hospitals have a dedicatedsmoking cessation specialist

Costs of a secondary care service

• Staff: 2 part-time specialists (Band 6) (£31,800)

• NRT: (£12000) see later

• Consumables: room, telephone, photocopying (£1000)

(eCO monitors -free)

• Publicity (£7000 WAG monies)

TOTAL: £45, 000

Publicity:

Who refers to the HSSS? (n=513 between 2007-2008)

Results (0-3 years)

Patients: n=1033,SVQR 28%. Referral rate was increasing

Staff:

-84 attended, 32 sustained quitters (saving approx £32K)

Research / publicity /teaching:Research / publicity /teaching:

-2 papers, 1 book, 12 abstracts, invited talks (worldwide!)

-medical student elective placement

-1 portfolio, 1 pharmaceutical study

- Core Competency in FP1 and FP2, ST training week

Risks of not meeting the secondary care need

• Patients: Breaking NICE Guidance, more ill health, more costs,

despite highest level of medical evidence and local validation /

business cases

• Staff: more sickness, extra breaks, fire insurance

• Teaching: none

• Political: difficult to implement national and HB Policies

http://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspx

Secondary care and community services – joined up??

Hospital

•More motivated to quit because

of acute symptoms

•Smoking is prohibited

•Less triggers

Community

•Closer to home

•Flexibility

•No parking fees!•Less triggers

•Pharmacotherapy readily

available

•Medical support for drug

interactions, illnesses

•No parking fees!

•Less of an illness

•Longer-term

relationships

150 PATIENTS150 PATIENTS 150 PATIENTS 150 PATIENTS

450 PATIENTS450 PATIENTSrandomisedrandomised

450 PATIENTS450 PATIENTSrandomisedrandomised

Counsellor1 week2 weeks3 weeks4 weeks

Counsellor1 week2 weeks3 weeks4 weeks

Advice / NRTTel no. / Leaflet

Validated CO-3 months-6 months-12 months

Tel no. / Leaflet

Validated CO-3 months-6 months-12 months

Validated CO-3 months-6 months-12 months

Phone / faxDIRECT referral

J Tob Nicotine Res 2009; 11: 756-64

Joined up working?

•Hospitalised smokers don’t switch to a community service

•Hospitals merely referring to a Community Service are not

helping their patients

•Having a Community Specialist doing 1-2 sessions per week

is probably not enough

Only 4 from 17 Welsh hospitals have a dedicatedsmoking cessation specialist

Key Challenges / Vision for the future

Increase provision in secondary care

Standardise service in secondary care

Standardise data sets in secondary care

Increase referrals to / awareness of SCS in secondary care

Research

Aged 33

Bryan Curtis aged 34from

St Petersburg Times 1999

(www.whyquit.com)

Summary

•Smoking cessation within secondary care is needed

•Smoking cessation within secondary care is clinically effective

and extremely cost-effective

•Smoking cessation provision within secondary care in Wales

is very low (<25%) and is the lowest the UK