A national initiative to help smokers quit: the English experience

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

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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

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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)

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England No. Treated 4 Week Quitters
CO-verified 4-week quitters 33
Slide from Gay Sutherland, Kings College London
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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
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Number of prescriptions (2006-2007)

• 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
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