Supporting smoking cessation in primary and secondary care

Kruti Shrotri, Policy Manager, Tobacco Policy &

Dr Richard Roope, CRUK-RCGP Clinical Champion for Cancer

TOBACCO CONTROL: A PRIORITY

THE AMBITION

CRUK’s ambition: A smoke-free generation by 2035 across all socioeconomic groups

Biggest cause of avoidable illness and

deathCauses 15% of all cancer cases, 1 in 4

cancer deaths

Half the difference in

life expectancy

between rich/poor

Costs: £12.6bn per year (£2.5bn on the NHS)

Cost-effective intervention

Smoking cessation interventions are some of the most cost-effective available

Stop Smoking Services - £6000 per QALYIncreases chances of quitting by three times

Pharmacotherapy - £316 - £3554 per QALYIncreases chances of quitting by 60% when delivered with brief advice

OUR RECOMMENDATIONS FOR PRIMARY AND SECONDARY CARE

Healthcare professionals across primary care and secondary care should routinely identify patients who smoke and support them to quit, for example via Very Brief Advice

Offering support to quit smoking can be through referral to a Stop Smoking Service or prescribing a Stop Smoking medication with brief advice

Training on Very Brief Advice is available online through the NCSCT and CRUK/RCGP

ROUTINE IDENTIFICATION AND TREATMENT

The NHS should work jointly with local authorities to create seamless referral pathways from the NHS to Stop Smoking Services

Smokers are around three times more likely to quit using Stop Smoking Services compared to attempting to quit alone.

In 2016/17, almost 1/3 of referrals to stop smoking services were prompted by GPs

REFERRAL TO A STOP SMOKING SERVICE

CCGs and health professionals should ensure that pharmacotherapy for smoking cessation is available on prescription from GPs and prescribing nurses

In England, levels of NRT dispensed in primary care in 2016-17 were around 25% of what was dispensed in 2005-06

PHARMACOTHERAPY ON PRESCRIPTION

The NHS should support the use of e-cigarettes as an aid to stop smoking – in line with NICE guidance NG92

The evidence so far shows e-cigarette use is much less harmful than smoking and that they are helping people to quit –contributed to 18,000 long-term ex-smokers in 2015

Regional groups (STPs, CAs) could develop a position statement on e-cigarettes. See for example the RCGP-CRUK joint position statement

E-CIGARETTES AS A QUITTING TOOL

National mandate: the Government’s Tobacco Control Plan for England

Regional mandates: STPs and Cancer Alliances can identify tobacco dependency as a priority, and develop regional tobacco control strategies joining up NHS and LA action

CCGs and Trusts should appoint a clinical smoke-free lead to be responsible for driving forward treatment of tobacco dependency

CCGs can use commissioning mechanisms

HOW TO DRIVE FORWARD ACTION?

SMOKING DATA:

PREVALENCE, MORTALITY & INEQUALITIES

Cancer Cascade 22/11/18

Smoking prevalence

15.1% 14.9%

16.3% 16.1%16.5%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

UK England Scotland Wales Northern Ireland

Smoking in adults

http://ash.org.uk/category/information-and-resources/fact-sheets/

https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2017#the-proportion-who-are-current-smokers-in-the-uk-its-constituent-countries-and-local-areas-2011-to-2017 Accessed 17.11.18

Proportion who were current smokers, all persons aged 18 years and over

Smoking prevalence

https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2017#the-proportion-who-are-current-smokers-in-the-uk-its-constituent-countries-and-local-areas-2011-to-2017 Accessed 17.11.18

Smoking data (2017)• 25-34 yos highest smoking rates 19.7%• 18-24 yos largest fall in prevalence:

– 2011: 25.7%– 2017: 17.8%

Smoking data (2017)• Routine and manual occupations: 25.9%• Intermediate occupations: 16.2%• Managerial and professional: 10.2%

https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2017#the-proportion-who-are-current-smokers-in-the-uk-its-constituent-countries-and-local-areas-2011-to-2017 Accessed 17.11.18

Smoking data

https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2017#the-proportion-who-are-current-smokers-in-the-uk-its-constituent-countries-and-local-areas-2011-to-2017 Accessed 17.11.18

The proportion who were current smokers by socio-economic status group, those aged 18 to 64 years 2014-2017

Smoking data

https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-smoking/statistics-on-smoking-england-2018/part-3-smoking-patterns-in-adults Accessed 17.11.18

Smoking prevalence, by qualifications

Smoking data• Mothers smoking at time of birth: 10.8%

https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-women-s-smoking-status-at-time-of-delivery-england/statistics-on-womens-smoking-status-at-time-of-delivery-england---quarter-4-october-2017-to-december-2017/content Accessed 17.11.18

Smoking data (2017)• 1/3 of all tobacco is smoked by people

with mental health condition

Smoking and mental health: A joint report by the Royal College of Physicians and the Royal College of Psychiatrists, Royal College of Physicians/Royal College of Psychiatrists. Accessed 17.11.18

Smoking mortality

https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-smoking/statistics-on-smoking-england-2018/part-1-smoking-related-ill-health-and-mortality#smoking-related-ill-health Accessed on 17.11.18

Smoking Inequalities

“Smoking is the leading cause of health inequalities with the difference in smoking rates between socio-economic groups responsible for half the difference in life expectancy”

Marmot, M., ‘Fair Society, Healthy Lives’, The Marmot Review, 2010

SMOKING CESSATION

Cancer Cascade 22/11/18

Smoking cessation data

https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-smoking/statistics-on-smoking-england-2018/part-2-prescription-items-used-to-help-people-stop-smoking. Accessed 17.11.18

Smoking cessation data

https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-smoking/statistics-on-smoking-england-2018/part-2-prescription-items-used-to-help-people-stop-smoking. Accessed 17.11.18

Prescription items dispensed by Clinical Commissioning Group, per 1,000 population

ASH (Action on smoking and health) 8.5.17

Reality of Harm

http://ash.org.uk/category/information-and-resources/fact-sheets/ Accessed 17.11.18

ASH (Action on smoking and health) 8.5.17

Reality of Harm

http://ash.org.uk/category/information-and-resources/fact-sheets/ Accessed 17.11.18

ASH (Action on smoking and health) 8.5.17

Reality of Harm

http://acqprod01.prod.acquia-sites.com/about-us/we-develop-policy/our-policy-on-preventing-cancer/our-policy-on-tobacco-control-and-cancer/our-policy-on-e-cigarettes

ASH (Action on smoking and health) 8.5.17

http://ash.org.uk/category/information-and-resources/fact-sheets/ Accessed 17.11.18

Smoking prevalence• 2018: 15.1% - still 7.4 million smokers

Smoking prevalence• 2018: 15.1% - still 7.4 million smokers• Average 230 per F/T GP

Smoking prevalence• 2018: 15.1% - still 7.4 million smokers• Average 230 per F/T GP• Still 95,800 deaths pa attributed to smoking

https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2017 Accessed 17.11.18

Smoking cessation

– Cessation medication + support=best results

– Since 2013 e-cigarettes have been most popular quitting aid

– In 2015 ECs contributed to 18,000 long term ex-smokers

ASH (Action on smoking and health) 8.5.17

• 7.4 million still smoke• Of these only 43% of those who have never

tried vaping correctly identify vaping as less harmful than smoking…

E-cigarettesE-cigarettes – re-position statement

• Using their clinical judgement on an individual patient basis, PCCs may wish to promote EC use as a means to stopping. Patients choosing to use an e-cigarette in a quit attempt should be advised that seeking behavioural support alongside e-cigarette use increases the chances of quit success further. Most SSS are EC friendly and patients can be advised to bring one to their appointment if they would like to quit using their device

E-cigarettesE-cigarettes – re-position statement

• Using their clinical judgement on an individual patient basis, PCCs may wish to promote EC use as a means to stopping. Patients choosing to use an e-cigarette in a quit attempt should be advised that seeking behavioural support alongside e-cigarette use increases the chances of quit success further. Most SSS are EC friendly and patients can be advised to bring one to their appointment if they would like to quit using their device

E-cigarettesE-cigarettes – re-position statement

• PCCs recognise ECs offer a wide reaching, low-cost opportunity to reduce smoking (especially in deprived groups in society and those with poor mental health, both having elevated rates of smoking). In the UK, though start-up costs can be higher, it likely to be less expensive to use an EC over time than it is to smoke

E-cigarettesE-cigarettes – re-position statement

• PCCs recognise ECs offer a wide reaching, low-cost opportunity to reduce smoking (especially in deprived groups in society and those with poor mental health, both having elevated rates of smoking). In the UK, though start-up costs can be higher, it likely to be less expensive to use an EC over time than it is to smoke

TOOLS AND RESOURCES TO SUPPORT YOU

Cancer Cascade 22/11/18

Online learning– E-cigarettes – RCGP podcast1 and video2:

Suitable for the busy GP – 10 minutes long

Addresses key concerns around safety, passive vaping and entry into smoking

– Webinar3 – Smoking cessation: Why and how to support your patients to stop smoking (when time and funding are against us!)

Suitable for the busy GP – 20 minutes long

Addresses current smoking cessation strategies available to GPs

– E-learning modules– VBA and Smoking cessation

Behaviour change and cancer prevention

Essentials of smoking cessation

30 minutes each, offering practical support1. https://audioboom.com/posts/6981730-let-s-talk-about-e-cigarettes2. https://www.cancerresearchuk.org/health-professional/awareness-and-

prevention/e-cigarette-hub-information-for-health-professionals/expert-talking-heads#expert_talking_heads1

3. https://www.cancerresearchuk.org/health-professional/awareness-and-prevention/smoking-cessation

“I FEEL LESS

WORRIED ABOUT

PATIENTS USING E

CIGARETTES”

“I’M GOING TO

RECOMMEND

VAPING 1ST TIME”

Feedback from GPs who have learnt about the RCGP e-cigarettes position statement

INFOGRAPHICS