The Role of Cessation Services in Quitting Smoking and Future Directions
With over 4000 chemicals in a single puff of a cigarette (60 of which are carcinogens)[i], it should come as no surprise why smoking is the single leading cause of preventable illness and premature deaths in the UK. Around 90,000 people are estimated to die each year from a smoking related illness in England alone[ii]. Nicotine, Tar and Carbon Monoxide are the three main chemicals linked with the numerous illnesses that account for the high morbidity and mortality associated with smoking. Nicotine is the chemical that causes addiction, while tar and carbon monoxide are associated with lung cancer, chronic obstructive pulmonary disease (COPD), coronary heart disease, stroke and peripheral vascular disease that arise from cigarette smoking. This combination of illnesses makes tobacco smoking the biggest killer in the country. In addition to the detrimental health effects to the smoker and those around him/her, smoking places an immense burden upon National Health Service (NHS) resources. The direct cost of smoking to the NHS has been estimated to range from £1.4 billion pounds per year in 1991 to £5 billion pounds per year in 2005-2006[iii].
In 1998, the government published a white paper, Smoking Kills, which outlined a comprehensive strategy to reduce the prevalence of smoking in England. The tobacco control strategy is split into six strands. These are:
- Reducing exposure to secondhand smoke
- Tobacco media/education campaigns
- Reducing availability of tobacco products and regulating supply
- Reducing tobacco advertising and promotion
- Regulating tobacco products
- NHS Stop Smoking Service.
The main aims of the tobacco control strategy as outlined in the white paper were to reduce the number of under-16s who smoke, help adults (especially the disadvantaged) to stop smoking and provide special support for pregnant women. To accomplish these goals, theNHS Stop Smoking Service was set up in order to provide counselling and support to smokers wanting to quit. In its first decade (1999-2009), the service has helped some 2 million people quit and has contributed to the prevalence of smoking falling from 28% to below 21% in England[iv]. This fall in prevalence is undoubtedly due to the cumulative effect of the tobacco control agenda set out in the white paper. In addition to being highly effective, the intervention provided by the NHS Stop Smoking Service is also cost effective with an incremental cost per QALY of £4,800 for group support and £2,600 for one-one counselling[v]. This is below the £20,000 to £30,000 threshold applied by the National Institute for Health and Clinical Excellence (NICE)[vi].
The NHS Stop Smoking Service in England is made up of three tiers; Brief Intervention, Intermediate (level 2) advice and Specialist (level 3) advice. Brief Intervention is a simple opportunistic advice to stop smoking. Ideally, all health professionals should ask patients/clients about their smoking status (i.e. smoker, ex-smoker or non-smoker), assess willingness to quit, give advice on the benefits of quitting and when ready, refer their patients to the NHS Stop Smoking Service. Once referred to the service, smokers get free access to either intermediate or specialist stop smoking advisors who are trained to provide smokers with enhanced counselling and behavioural support as well as pharmacotherapy to assist with nicotine addiction.
Nicotine is one of the most powerful addictive substances which explains why quitting smoking and staying quit is notoriously difficult. Several studies have shown that combining pharmacotherapy with behaviour counselling increases a smoker’s odds of successfully quitting[vii],[viii]. Behavioural support is especially important because many experts believe that smoking is 90% psychological addiction and 10% physical addiction to Nicotine[ix]. NHS stop smoking advisors are trained to provide smokers with behavioural support in the form of counselling, discussions and exercises in order to maximise motivation and help clients cope with withdrawal symptoms[x].
To combat the physical addiction to Nicotine, the NHS Stop Smoking Service provides smokers with pharmacotherapy. Stop smoking medications currently licensed are Nicotine Replacement Therapy (NRT), Zyban (Buproprion) or Champix (Varenicline). NRT can be in the form of patches, gum, lozenges, nasal spray, microtabs or inhalators. The three medications help counter the withdrawal effects of nicotine and, according to NICE guidelines, no one product should be favoured over another[xi]. The success of the NHS Stop Smoking Service can be attributed to the combination of pharmacotherapy with intense behaviour counselling and monitoring from dedicated and highly motivated stop smoking specialists.
Smoking has been identified as the largest cause of health inequalities in the United Kingdom. Smoking rates are markedly higher among poorer people with 15% of men in higher managerial occupations smoking, compared with 39% in routine occupations in 2003[xii]. The NHS Stop Smoking Service has a very important role to play in reducing these inequalities in the future. In order to meet this challenge, the current strategy encourages the provision of easy access, tailored interventions for hard-to-reach groups such as routine and manual smokers, pregnant smokers, and smokers with a mental disorder. Smokers with a mental disorder account for 42% of the tobacco consumption in the UK[xiii]. Reducing the prevalence of smoking among these groups is crucial in bringing down the prevalence of smoking at the national level.
One other important strategy is preventing uptake of smoking among children and young people. NICE public health guidance 14 recommends that all those responsible for the health and wellbeing of children and young people under 18 to focus on mass-media and point-of-sales measures, combined with education and cessation support to prevent the uptake of smoking among children and young people. The guidance is aimed at those working in the NHS, local authorities, the criminal justice system and the wider public, voluntary and community sectors.
[i]Hecht, S. S. (2002). Cigarette smoking and lung cancer: chemical mechanisms and approaches to prevention. The Lancet Oncology. 3: 461-469.
[ii]Department of Health (2008). Excellence in tobacco control. England: Department of Health
[iii]Allender, S., Balakrishnan, R., Scarborough. P., Webster, P and Rayner, M. (2009). The burden of smoking-related ill health in the UK. Tobacco Control. 18 (4), 262-267.
[iv]Cancer Research UK. (2009). NHS Stop Smoking Services save 70,000 lives in ten years. Available: http://info.cancerresearchuk.org/news/archive/cancernews/2009-09-24-NHS-Stop-Smoking-Services-save-70000-lives-in-ten-years#. Last accessed 10th April 2011.
[v]Bauld. L., Boyd, K. A., Briggs, A. H., Chesterman, J., Ferguson, J., Judge, K. and Hiscock, R. (2010). One-Year Outcomes and a Cost-Effectiveness Analysis for Smokers Accessing Group-Based and Pharmacy-Led Cessation Service. Nicotine and Tobacco Research. 13 (2), 135-145.
[vi]Drummond, M. (2009). What are the HTA processes in the UK? London: Hayward Medical Communications.
[vii]Silagy C, Mant D, Fowler G. et alNicotine replacement therapy for smoking cessation (Cochrane Review, May 1998). In: The Cochrane Library. Oxford: Update software, 2002. (4)
[viii]Silagy C. Physician advice for smoking cessation (Cochrane Review, November 1998). In: The Cochrane Library. Oxford: Update software, 2002. (4)
[ix]Wolbers, P. (2005). How to beat cigarettes with psychology. Available: http://www.articledestination.com/Article/How-To-Beat-Cigarettes-With-Psychology/8996. Last accessed 14th April 2010.
[x]NHS Stop Smoking Service. (2009). Service and Monitoring Guidance 2010/2011. Crown Copyright.
[xi]National Institute of Health and Clinical Excellence. (2008). Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. NICE Public Health Guidance 10.
[xii]Crosier. A, (2005). Smoking and Health Inequalities: factsheet. London: Public Health Research Consultant
[xiii]McManus S, Meltzer H and Campion J (2010) Cigarette Smoking and Mental Health in England: Data from the Adult Psychiatric Morbidity Survey 2007. National Centre for Social Research. www.natcen.ac.uk/study/cigarette-smoking--mental-health