UK/NI/14-2970

1
Increasing footfall and driving quit rates in a
challenging environment
Guest speakers Emma Croghan, Mary Campbell
Sonia Simkins UKNSCC 2014
Organised and funded by Johnson Johnson Ltd.,
owners of
Prescribing information can be found at the end
of this presentation
UK/NI/14-2970 Date of preparation June 2014
2
Todays agenda

• 15 years on Stop Smoking Services (SSS), a
  victim of their own success?
• Smoking Cessation (SC) in Secondary Care
• Smoking Cessation in Primary Care
• Group discussion and QA

3
The Quitting Edge programme

• Quitting Edge (QE) a long-term initiative to
  support HCPs and SSSs in providing high quality
  advice, support treatment
• QE takes a pragmatic approach to share real-life
  examples and learnings from peers and colleagues
  across the country
• It focuses on the role of engagement and
  collaboration in helping deliver on the ambitious
  targets set

HCP - Healthcare Professional
4
15 years on Stop Smoking Services, a victim of
their own success?

• Emma Croghan
• Director of Public Health and Lifestyle Services,
  North 51

5
We know footfall to SSSs is in decline 1

• There might be a number of reasons for this
• There is a wide variation in footfall and quit
  rates from service to service1
• Why is that?

6
What does this mean for SSSs?

• Still 10 million smokers out there2
• 16.6 have tried quitting smoking in the last 3
  months3
• There is an opportunity here, at both secondary
  care and primary care level to fish where the
  fish are

7
How can you make your servicemore visible?

• ASK some questions!
• Is it visible to referrers/smokers?
• What do referrers/potential partners know and
  need?

• Who could you work in partnership with to drive
  footfall?

8
Smoking Cessation in Secondary Care

• An interview with Mary Campbell
• Stop Smoking and Prevention Coordinator, Western
  Trust, Northern Ireland

9
The opportunity in secondary care

• We know that lots of smokers go into secondary
  care each year, in England, approximately 1.6m
  admissions a year are smoking related among
  adults of 35 years and over4 plus all the
  smokers who go with an unrelated condition
• In a pilot study comprising 1097 patients, 31 of
  the hospital population were smokers 5 which is
  considerably higher than the national average
  (20)2
• Acting on teachable moments motivation is fluid

10
Emmas maths

• If we assume
• 20 took the referral, then there would be
  320,000 referrals alone from the smoking related
  admissions group
• Every third bed contains a smoker if 20 take
  the referral this would mean A ward of 20 beds
  at any time at least 6 will be smokers and 1 will
  take the referral
• Therefore broadly every 100 beds should deliver
  5 referrals (minimum) per week on average

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My current role in secondary care

• Coordination of smokefree campus implementation
• Planning and coordination of stop smoking
  services
• Develop / design care pathways / clinical
  management plans / electronic referral
• Develop / implement education programmes within
  secondary care e learning
• Leader, manager, clinician, research

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Encouraging quitters in acute settings

• Challenges
• Time constraints
• Reduced in-patient periods
• Skill mix
• Its everyones job
• Support for staff to quit
• Get families to quit

• How do you overcome barriers to providing smoking
  cessation to secondary care patients?
• Training specific to each specialism
• Offer training at each opportunity
• CO monitoring
• Mentor clinical staff
• Make referral easy (ex electronic referral)
• Immediate access to pharmacotherapy and
  behavioural support PGD
• Use of NRT

• How can you motivate other HCPs in secondary care
  to get involved in smoking cessation?
• Be visible, approachable, helpful
• Feedback to staff on patients quitting

 PGD - Pre-implantation genetic diagnosis 
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Service collaboration with secondary care

• Seamless service continuity of care
• Contacts for services pre, during and post
  admission
• Adequate NRT given on discharge
• Posters / fliers on services available
• Leaflets benefits of quitting, risks of SHS
• Motivating smokers to quit individualise the
  information / listen to the client

SHS Second hand smoke
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Who can you target in secondary care ?

• Respiratory, acute medical units, antenatal and
  post natal, outpatient clinics, paediatrics and
  neonatal units

• Liaise with HCPs, Managers, HCAs, support staff
• Hospital admission teachable moment
  professional and moral duty to help smokers to
  quit

HCA - HealthCare Assistant
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3 take-home messages

• Hospital admission teachable moment
  professional and moral duty to help smokers to
  quit
• Make every contact count
• Quit for life improvement

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Smoking Cessation in Primary care

• An interview with Sonia Simkins
• Practice Manager, Rowley Healthcare

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What about opportunities in primary care?

• The UK population saw their GP on average 6.4
  times in 2013 6

• 30 of quit attempts were triggered by advice
  from an HCP7
• However, many barriers to working in primary care
  and we need to be able to sell it into the
  practice

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Emmas maths

• Lets assume a practice of 5,000 patients
• We can suppose that 20 of them are smokers (as
  per national average smoking prevalence2). This
  means there are 1,000 smokers in this practice
• Lets assume that out of these 1,000 smokers, 700
  visit this practice per year
• Finally, lets assume, 20 of those 700 take up
  the referralThis would equal 140 referrals to a
  Stop Smoking Service per year for that practice

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Objectives

• Decide as an organisation/practice if helping
  patients to quit smoking is a priority
• Is it a realistic goal? Look at the category of
  patients!
• Is the process manageable from a practice point
  of view

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Challenges

• All staff must be on board with the project for
  it to be a success
• Referral system should be quick and easy to
  follow for staff and patients
• The clinics need to run effectively
• It is essential there is a good working
  relationship with the advising team
• All staff to be informed about the project and
  have access to the information explaining the
  service

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Success?

• Referral forms placed in every clinical room
• Encouragement from referring staff to ensure
  patients are on board with the process!!!
• Efficient correspondence between the practice and
  service provider i.e Q51
• Referrals managed efficiently by Practice Staff

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3 take-home messages

1. Referral system
2. Efficient correspondence
3. Encouragement from referring staff

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• Discussion and QA
• What do you think?

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QE Resource Stick

• Features valuable insights from the smoking
  cessation field including
• Tips on understanding and engaging smokers from
  different backgrounds
• Information on treatment interventions such as
  Nicotine Replacement Therapy
• Guidance on quit strategies and harm reduction
• A step by step guide to collaborating with peers
• It is available free

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References

• Statistics on NHS Stop Smoking Services England
  April 2012 March 2013. Published 30 October
  2013
• ASH Smoking Statistics Factsheet. October 2013
• R. West. Smoking Toolkit Study Trends in
  electronic cigarette use in England. Updated 21
  March 2014
• HSCIC. Statistics on smoking England, 2013.
  Published 15 August 2013
• NCSCT. Stop smoking interventions in secondary
  care. August 2012
• NHS England Analytical Service. Improving GP a
  call to action, Evidence Pack. August 2013/14
• R. West et al. Key findings from the Smoking
  Toolkit Study. 2012

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• Adverse events should be reported. Reporting
  forms and information can be found at
  www.mhra.gov.uk/yellowcard.
• Adverse events should also be reported to McNeil
  Products Limited on
• 01344 864 042

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Nicorette Invisi Patch Prescribing Information

• Presentation Transdermal delivery system
  available in 3 sizes (22.5, 13.5 and 9cm2)
  releasing 25mg, 15mg and 10mg of nicotine
  respectively over 16 hours. Uses Nicorette
  Invisi Patch relieves and/or prevents craving and
  nicotine withdrawal symptoms associated with
  tobacco dependence. It is indicated to aid
  smokers wishing to quit or reduce prior to
  quitting, to assist smokers who are unwilling or
  unable to smoke, and as a safer alternative to
  smoking for smokers and those around them.
   Nicorette Invisi Patch is indicated in pregnant
  and lactating women making a quit attempt. If
  possible, Nicorette Invisi Patch should be used
  in conjunction with a behavioural support
  programme.   Dosage It is intended that the
  patch is worn through the waking hours
  (approximately 16 hours) being applied on waking
  and removed at bedtime.  Smoking Cessation
  Adults (over 18 years of age) For best results,
  most smokers are recommended to start on 25 mg /
  16 hours patch (Step 1) and use one patch daily
  for 8 weeks.  Gradual weaning from the patch
  should then be initiated.  One 15 mg/16 hours
  patch (Step 2) should be used daily for 2 weeks
  followed by one 10 mg/16 hours patch (Step 3)
  daily for 2 weeks.  Lighter smokers (i.e. those
  who smoke less than 10 cigarettes per day) are
  recommended to start at Step 2 (15 mg) for 8
  weeks and decrease the dose to 10 mg for the
  final 4 weeks.   Those who experience excessive
  side effects with the 25 mg patch (Step 1), which
  do not resolve within a few days, should change
  to a 15 mg patch (Step 2).  This should be
  continued for the remainder of the 8 week course,
  before stepping down to the 10 mg patch (Step 3)
  for 4 weeks.  If symptoms persist the advice of a
  healthcare professional should be sought.
  Adolescents (12 to 18 years)  Dose and method of
  use are as for adults however, recommended
  treatment duration is 12 weeks.  If longer
  treatment is required, advice from a healthcare
  professional should be sought. Smoking
  Reduction/Pre-Quit Smokers are recommended to
  use the patch to prolong smoke-free intervals and
  with the intention to reduce smoking as much as
  possible.  Starting dose should follow the
  smoking cessation instructions above i.e. 25mg
  (Step 1) is suitable for those who smoke 10 or
  more cigarettes per day and for lighter smokers 
  are recommended to start at Step 2 (15 mg). 
  Smokers starting on 25mg patch should transfer to
  15mg patch as soon as cigarette consumption
  reduces to less than 10 cigarettes per day.   A
  quit attempt should be made as soon as the smoker
  feels ready. When making a quit attempt smokers
  who have reduced to less than 10 cigarettes per
  day are recommended to continue at Step 2 (15 mg)
  for 8 weeks and decrease the dose to 10 mg (Step
  3) for the final 4 weeks. Temporary Abstinence
  Use a Nicorette Invisi Patch in those situations
  when you cant or do not want to smoke for
  prolonged periods (greater than 16 hours).  For
  shorter periods then an alternative intermittent
  dose form would be more suitable (e.g. Nicorette
  inhalator or gum).  Smokers of 10 or more
  cigarettes per day are recommended to use 25mg
  patch and lighter smokers are recommended to use
  15mg patch.Contraindications Hypersensitivity.
  Precautions Unstable cardiovascular disease,
  diabetes mellitus, renal or hepatic impairment,
  phaeochromocytoma or uncontrolled
  hyperthyroidism, generalised dermatological
  disorders. Angioedema and urticaria have been
  reported.  Erythema may occur. If severe or
  persistent, discontinue treatment. Stopping
  smoking may alter the metabolism of certain
  drugs. Transferred dependence is rare and less
  harmful and easier to break than smoking
  dependence. May enhance the haemodynamic effects
  of, and pain response, to adenosine.  Keep out of
  reach and sight of children and dispose of with
  care. Pregnancy and lactation Only after
  consulting a healthcare professional. Side
  effects Very common itching.  Common headache,
  dizziness, nausea, vomiting, GI discomfort
  Erythema. Uncommon palpitations, urticaria. Very
  rare reversible atrial fibrillation. See SPC for
  further details. NHS Cost 25mg packs of 7
  (9.97) 25mg packs of 14 (16.35) 15mg packs
  of 7 (9.97) 10mg packs of 7 (9.97). Legal
  category GSL.  PL holder McNeil Products Ltd,
  Roxborough Way, Maidenhead, Berkshire, SL6 3UG.
  PL numbers 15513/0161 15513/0160 15513/0159. 
  Date of preparation Feb 2012

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Nicorette QuickMist Mouthspray Prescribing
Information

• Presentation oromucosal spray containing 13.2ml
  solution. Each 0.07 ml contains 1 mg nicotine,
  corresponding to 1 mg nicotine/spray dose. Uses
  Relieves and/or prevents craving and nicotine
  withdrawal symptoms associated with tobacco
  dependence. It is indicated to aid smokers
  wishing to quit or reduce prior to quitting, to
  assist smokers who are unwilling or unable to
  smoke, and as a safer alternative to smoking for
  smokers and those around them. It is indicated in
  pregnant and lactating women making a quit
  attempt. Dosage Adults and Children over 12
  years of age The patient should make every
  effort to stop smoking completely during
  treatment with Nicorette QuickMist. One or two
  sprays to be used when cigarettes normally would
  have been smoked or if cravings emerge. If after
  the first spray cravings are not controlled
  within a few minutes, a second spray should be
  used. If 2 sprays are required, future doses may
  be delivered as 2 consecutive sprays. Most
  smokers will require 1-2 sprays every 30 minutes
  to 1 hour. Up to 4 sprays per hour may be used
  not exceeding 2 sprays per dosing episode and 64
  sprays in any 24-hour period. Nicorette
  QuickMist should be used whenever the urge to
  smoke is felt or to prevent cravings in
  situations where these are likely to occur.
  Smokers willing or able to stop smoking
  immediately should initially replace all their
  cigarettes with the Nicorette QuickMist and as
  soon as they are able, reduce the number of
  sprays used until they have stopped completely.
  When making a quit attempt behavioural therapy,
  advice and support will normally improve the
  success rate. Smokers aiming to reduce cigarettes
  should use the Mouthspray, as needed, between
  smoking episodes to prolong smoke-free intervals
  and with the intention to reduce smoking as much
  as possible. Contraindications Children under
  12 years and Hypersensitivity. Precautions
  Unstable cardiovascular disease, diabetes
  mellitus, G.I disease, uncontrolled
  hyperthyroidism, phaeochromocytoma, hepatic or
  renal impairment. Stopping smoking may alter the
  metabolism of certain drugs. Transferred
  dependence is rare and both less harmful and
  easier to break than smoking dependence. May
  enhance the haemodynamic effects of, and pain
  response to, adenosine. Keep out of reach and
  sight of children and dispose of with care.
  Pregnancy lactation Only after consulting a
  healthcare professional. Side effects Very
  common dysgeusia, headache, hiccups, nausea and
  vomiting symptoms, dyspepsia, oral soft tissue
  pain and paraesthesia, stomatitis, salivary
  hypersecretion, burning lips, dry mouth and/or
  throat. Common dizziness, vomiting, flatulence,
  abdominal pain, diarrhoea, , throat tightness,
  fatigue, chest pain and discomfort, toothache.
  Other palpitations, atrial fibrillation,
  dyspnoea, bronchospasm . See SPC for further
  details. NHS Cost 1 dispenser pack 12.12, 2
  dispenser pack 19.14. Legal category GSL. PL
  holder McNeil Products Ltd, Roxborough Way,
  Maidenhead, Berkshire, SL6 3UG. PL number
  15513/0357. Date of preparation October 2013

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Nicorette 15 mg Inhalator Prescribing
Information

• Presentation Inhalation cartridge containing
  15mg nicotine for oromucosal use via a
  mouthpiece. Uses Relieves and/or prevents
  craving and nicotine withdrawal symptoms
  associated with tobacco dependence. It is
  indicated to aid smokers wishing to quit or
  reduce prior to quitting, to assist smokers who
  are unwilling or unable to smoke, and as a safer
  alternative to smoking for smokers and those
  around them. It is indicated in pregnant and
  lactating women making a quit attempt. Dosage
  Adults and Children over 12 years of age
   Nicorette Inhalator should be used whenever the
  urge to smoke is felt or to prevent cravings in
  situations where these are likely to occur.  
  Smokers willing or able to stop smoking
  immediately should initially replace all their
  cigarettes with the Inhalator and as soon as they
  are able, reduce the number of cartridges used
  until they have stopped completely.  Smokers
  aiming to reduce cigarettes should use the
  Inhalator, as needed, between smoking episodes to
  prolong smoke-free intervals and with the
  intention to reduce smoking as much as possible. 
  As soon as they are ready smokers should aim to
  quit smoking completely.  Maximum of 6 cartridges
  per day should be used.  When making a quit
  attempt behavioural therapy, advice and support
  will normally improve the success rate. Those who
  have quit smoking, but are having difficulty
  discontinuing their Inhalator are recommended to
  contact their pharmacist or doctor for advice. 
  Contraindications Children under 12 years and
  Hypersensitivity. Precautions Unstable
  cardiovascular disease, diabetes mellitus, G.I
  disease, uncontrolled hyperthyroidism,
  phaeochromocytoma, hepatic or renal impairment,
  chronic throat disease, obstructive lung disease
  or bronchospastic disease. Stopping smoking may
  alter the metabolism of certain drugs.
  Transferred dependence is rare and both less
  harmful and easier to break than smoking
  dependence. May enhance the haemodynamic effects
  of, and pain response to, adenosine.  Keep out of
  reach and sight of children and dispose of with
  care. Best used at room temperature. Pregnancy
  lactation Only after consulting a healthcare
  professional. Side effects Cough, irritation of
  throat and mouth, headache, nasal congestion,
  nausea, vomiting, hiccups, palpitations, GI
  discomfort, dizziness, reversible atrial
  fibrillation. See SPC for further details. NHS
  Cost 4 cartridge pack 4.14, 20 cartridge pack
  14.03. 36 cartridge pack  22.33. Legal
  category GSL. PL holder McNeil Products Ltd,
  Roxborough Way, Maidenhead, Berkshire, SL6 3UG. 
  PL number 15513/0358. Date of preparation June
  2011