NIHR Signal NHS services can help in sustaining quit rates for smoking

Published on 23 December 2015

Almost eight per cent of users of NHS Stop Smoking services are still smoke-free after a year, compared with only about three per cent of smokers who try to quit without treatment. This NIHR-funded study added data on quit rates at one year to routinely collected short-term data, by showing England’s stop smoking services achieved a breath test validated quit rate of 8% after a year. Applying the findings to the whole of England, along with an estimated 35% relapse rate after one year, the researchers estimated that 36,249 smokers may have been helped to become lifelong abstinent quitters in England from use of the service.

The study also identified the predictors of short- and long-term stop smoking success. These included taking stop smoking medication and attending support sessions. Services vary widely and more research is needed to know which approaches are most cost-effective. Locally adaptable costing tools are available on the NICE website to help with this.

NHS services can help in sustaining quit rates for smoking

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Why was this study needed?

Despite declining rates over the last few decades, 18% of adults in England smoke cigarettes. Smoking costs the NHS in England an estimated £2.7 billion in 2006, in terms of hospital admissions, GP and nurse appointments and prescriptions for smoking-related health conditions. Government figures say around 75% of current smokers have tried to quit at some point in the past. To improve quit rates, the NHS Stop Smoking Services were founded and spread across the UK from 2000. The services offer a range of support to smokers including medications and one to one support delivered by health care professionals. A previous long-term evaluation of the national service drew on data from 2000 to 2004. As the service has changed more up to date statistics were needed. The researchers also wanted to look at factors linked with longer term success at stopping smoking.

What did this study do?

NHS Stop Smoking Services are provided in a range of settings – such as GP practices, community centres and pharmacies – and offer different interventions, such as one-to-one or group support, with or without medication or nicotine replacement therapy. This study, called ELONS, used three phases to evaluate the services. First, it analysed routine data on short-term quit rates from 49 NHS Stop Smoking Services in England, comprising 202,804 participant records between 2010 and 2011. Nine of these services took part in the second phase, a prospective observational study to confirm routine data figures and investigate longer-term quit rates, and the characteristics or treatments of 3,075 participants linked to success. The second phase also included three exploratory studies, in 2012/13. Participants were asked to take part in a service satisfaction survey, and wellbeing questionnaires at four and 52 weeks after quitting. The third phase was on longer term use of nicotine replacement therapy in the year after quitting, involving a third of the prospective study participants.

We can be confident in the quit-rate findings at both time points because they were measured objectively using a breath test and the figures were similar from routine and study data.

What did it find?

  • The routine NHS Stop Smoking Services data on 202,804 service users in 49 out of 150 services showed that up to 10% of smokers accessed their services. Of those, 34% successfully quit smoking for four weeks after setting a quit date, as confirmed by a breath test - the main stop smoking service performance measure.
  • In the smaller prospective study on 3,075 smokers, after four weeks 41% were validated as smoke free. This rate was slightly higher than for the routinely collected data.
  • After a year 8% in the prospective study remained smoke free, though 45% of people were lost to follow up (and recorded as smokers) by one year.
  • If the one year quit rates were applied to all of England (with an assumption that 35% of people relapse after a year) the researchers estimate 36,429 smokers would have quit for life using the help of the stop smoking services over a year.
  • Factors associated with quit success included:
    • attending group behavioural support or receiving one-to-one support from a specialist practitioner;
    • regularly taking varenicline – a stop smoking drug, or using nicotine replacement therapy;
    • being older, richer, or being less dependent on tobacco;
    • having support from a partner, or having non-smoking friends.
  • The majority of those accessing stop smoking services (79%) received one-to-one behavioural support, but taking part in an open support groups was found to be more effective by comparison (adjusted odds ratio 1.28, 95% confidence interval 1.15 to 1.41).
  • Findings from 996 participants in the satisfaction survey showed that both quitters and non-quitters viewed the service positively and would recommend it, although some reported the process of accessing medication was over complicated.

What does current guidance say on this issue?

NICE guidance from 2008 describes several evidence-based interventions for stop smoking services including individual behavioural counselling, group behaviour therapy and nicotine replacement therapy. This guidance recommends that services match local services to local needs, reach at least 5% of their smoking population in a year, and aim for breath-validated quit rates of 35% by four weeks of receiving services. Guidance implementation tools include costing reports, templates and a tobacco return on investment tool for local government. An updated version of the guidance on smoking cessation interventions and services is due to be published in October 2017.

Commissioning guidance from the National Centre for Smoking Cessation and Training, and NHS England (published in 2014) additionally recommends maximising referral opportunities for smokers from other parts of health and social care services.

What are the implications?

By providing new, long term data on service impact, the study estimated that NHS Stop Smoking services supported around 36,000 people to quit smoking successfully for life, in England in 2012. The large size of smoking population, smoking’s long term and costly health consequences, and the large numbers accessing stop smoking services mean that even a modest quit rate translates to a large impact in terms of health improvement, reducing health inequalities and generating savings in health care costs.

The study helped audit and validate routinely collected data on four week quit rates, which are to aim for a minimum target rate of 35%. It showed that routinely collected data are reliable. This confirms that ongoing data collection and analysis can support future assessment of service effectiveness.

The prospective study provided information about effective approaches, for example specialist support, and about what works for particular types of people, for example assessing well-being. These findings could help improve service design.

The study did not analyse whether stop smoking services are a cost effective use of resources in the short or long-term. NICE guidance on stop smoking services provides tools that can be adapted locally to estimate costs for a population.

Citation

Dobbie F, Hiscock R, Leonardi-Bee J, et al. Evaluating Long-term Outcomes of NHS Stop Smoking Services (ELONS): a prospective cohort study. Health Technol Assess. 2015;19(95):1-156.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 09/161/01). The UK Centre for Tobacco and Alcohol Studies provided funding for the longer-term nicotine replacement therapy study.

Bibliography

HSIC. Statistics on smoking: England 2015. Leeds: Health and Social Care Information Centre; 2015.

NHS. Smokefree NHS [internet]. NHS.

NCSCT. Local Stop Smoking Services. Service and delivery guidance 2014. London: National Centre for Smoking Cessation and Training, NHS England; 2014.

NICE. Stop smoking services. PH10. London: National Institute for Health and Care Excellence; 2008.

Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2012;(11):CD000146.

Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among

untreated smokers. Addiction. 2004;99(1):29–38.

Why was this study needed?

Despite declining rates over the last few decades, 18% of adults in England smoke cigarettes. Smoking costs the NHS in England an estimated £2.7 billion in 2006, in terms of hospital admissions, GP and nurse appointments and prescriptions for smoking-related health conditions. Government figures say around 75% of current smokers have tried to quit at some point in the past. To improve quit rates, the NHS Stop Smoking Services were founded and spread across the UK from 2000. The services offer a range of support to smokers including medications and one to one support delivered by health care professionals. A previous long-term evaluation of the national service drew on data from 2000 to 2004. As the service has changed more up to date statistics were needed. The researchers also wanted to look at factors linked with longer term success at stopping smoking.

What did this study do?

NHS Stop Smoking Services are provided in a range of settings – such as GP practices, community centres and pharmacies – and offer different interventions, such as one-to-one or group support, with or without medication or nicotine replacement therapy. This study, called ELONS, used three phases to evaluate the services. First, it analysed routine data on short-term quit rates from 49 NHS Stop Smoking Services in England, comprising 202,804 participant records between 2010 and 2011. Nine of these services took part in the second phase, a prospective observational study to confirm routine data figures and investigate longer-term quit rates, and the characteristics or treatments of 3,075 participants linked to success. The second phase also included three exploratory studies, in 2012/13. Participants were asked to take part in a service satisfaction survey, and wellbeing questionnaires at four and 52 weeks after quitting. The third phase was on longer term use of nicotine replacement therapy in the year after quitting, involving a third of the prospective study participants.

We can be confident in the quit-rate findings at both time points because they were measured objectively using a breath test and the figures were similar from routine and study data.

What did it find?

  • The routine NHS Stop Smoking Services data on 202,804 service users in 49 out of 150 services showed that up to 10% of smokers accessed their services. Of those, 34% successfully quit smoking for four weeks after setting a quit date, as confirmed by a breath test - the main stop smoking service performance measure.
  • In the smaller prospective study on 3,075 smokers, after four weeks 41% were validated as smoke free. This rate was slightly higher than for the routinely collected data.
  • After a year 8% in the prospective study remained smoke free, though 45% of people were lost to follow up (and recorded as smokers) by one year.
  • If the one year quit rates were applied to all of England (with an assumption that 35% of people relapse after a year) the researchers estimate 36,429 smokers would have quit for life using the help of the stop smoking services over a year.
  • Factors associated with quit success included:
    • attending group behavioural support or receiving one-to-one support from a specialist practitioner;
    • regularly taking varenicline – a stop smoking drug, or using nicotine replacement therapy;
    • being older, richer, or being less dependent on tobacco;
    • having support from a partner, or having non-smoking friends.
  • The majority of those accessing stop smoking services (79%) received one-to-one behavioural support, but taking part in an open support groups was found to be more effective by comparison (adjusted odds ratio 1.28, 95% confidence interval 1.15 to 1.41).
  • Findings from 996 participants in the satisfaction survey showed that both quitters and non-quitters viewed the service positively and would recommend it, although some reported the process of accessing medication was over complicated.

What does current guidance say on this issue?

NICE guidance from 2008 describes several evidence-based interventions for stop smoking services including individual behavioural counselling, group behaviour therapy and nicotine replacement therapy. This guidance recommends that services match local services to local needs, reach at least 5% of their smoking population in a year, and aim for breath-validated quit rates of 35% by four weeks of receiving services. Guidance implementation tools include costing reports, templates and a tobacco return on investment tool for local government. An updated version of the guidance on smoking cessation interventions and services is due to be published in October 2017.

Commissioning guidance from the National Centre for Smoking Cessation and Training, and NHS England (published in 2014) additionally recommends maximising referral opportunities for smokers from other parts of health and social care services.

What are the implications?

By providing new, long term data on service impact, the study estimated that NHS Stop Smoking services supported around 36,000 people to quit smoking successfully for life, in England in 2012. The large size of smoking population, smoking’s long term and costly health consequences, and the large numbers accessing stop smoking services mean that even a modest quit rate translates to a large impact in terms of health improvement, reducing health inequalities and generating savings in health care costs.

The study helped audit and validate routinely collected data on four week quit rates, which are to aim for a minimum target rate of 35%. It showed that routinely collected data are reliable. This confirms that ongoing data collection and analysis can support future assessment of service effectiveness.

The prospective study provided information about effective approaches, for example specialist support, and about what works for particular types of people, for example assessing well-being. These findings could help improve service design.

The study did not analyse whether stop smoking services are a cost effective use of resources in the short or long-term. NICE guidance on stop smoking services provides tools that can be adapted locally to estimate costs for a population.

Citation

Dobbie F, Hiscock R, Leonardi-Bee J, et al. Evaluating Long-term Outcomes of NHS Stop Smoking Services (ELONS): a prospective cohort study. Health Technol Assess. 2015;19(95):1-156.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 09/161/01). The UK Centre for Tobacco and Alcohol Studies provided funding for the longer-term nicotine replacement therapy study.

Bibliography

HSIC. Statistics on smoking: England 2015. Leeds: Health and Social Care Information Centre; 2015.

NHS. Smokefree NHS [internet]. NHS.

NCSCT. Local Stop Smoking Services. Service and delivery guidance 2014. London: National Centre for Smoking Cessation and Training, NHS England; 2014.

NICE. Stop smoking services. PH10. London: National Institute for Health and Care Excellence; 2008.

Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2012;(11):CD000146.

Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among

untreated smokers. Addiction. 2004;99(1):29–38.

Evaluating Long-term Outcomes of NHS Stop Smoking Services (ELONS): a prospective cohort study

Published on 1 November 2015

Dobbie F, Hiscock R, Leonardi-Bee J, Murray S, Shahab L, Aveyard P, Coleman T, McEwen A, McRobbie H, Purves R, Bauld L.

Health Technology Assessment Volume 19 Issue 95 , 2015

Background NHS Stop Smoking Services (SSSs) provide free at the point of use treatment for smokers who would like to stop. Since their inception in 1999 they have evolved to offer a variety of support options. Given the changes that have happened in the provision of services and the ongoing need for evidence on effectiveness, the Evaluating Long-term Outcomes for NHS Stop Smoking Services (ELONS) study was commissioned. Objectives The main aim of the study was to explore the factors that determine longer-term abstinence from smoking following intervention by SSSs. There were also a number of additional objectives. Design The ELONS study was an observational study with two main stages: secondary analysis of routine data collected by SSSs and a prospective cohort study of service clients. The prospective study had additional elements on client satisfaction, well-being and longer-term nicotine replacement therapy (NRT) use. Setting The setting for the study was SSSs in England. For the secondary analysis, routine data from 49 services were obtained. For the prospective study and its added elements, nine services were involved. The target population was clients of these services. Participants There were 202,804 cases included in secondary analysis and 3075 in the prospective study. Interventions A combination of behavioural support and stop smoking medication delivered by SSS practitioners. Main outcome measures Abstinence from smoking at 4 and 52 weeks after setting a quit date, validated by a carbon monoxide (CO) breath test. Results Just over 4 in 10 smokers (41%) recruited to the prospective study were biochemically validated as abstinent from smoking at 4 weeks (which was broadly comparable with findings from the secondary analysis of routine service data, where self-reported 4-week quit rates were 48%, falling to 34% when biochemical validation had occurred). At the 1-year follow-up, 8% of prospective study clients were CO validated as abstinent from smoking. Clients who received specialist one-to-one behavioural support were twice as likely to have remained abstinent than those who were seen by a general practitioner (GP) practice and pharmacy providers [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.2 to 4.6]. Clients who received group behavioural support (either closed or rolling groups) were three times more likely to stop smoking than those who were seen by a GP practice or pharmacy providers (OR 3.4, 95% CI 1.7 to 6.7). Satisfaction with services was high and well-being at baseline was found to be a predictor of abstinence from smoking at longer-term follow-up. Continued use of NRT at 1 year was rare, but no evidence of harm from longer-term use was identified from the data collected. Conclusions Stop Smoking Services in England are effective in helping smokers to move away from tobacco use. Using the 52-week CO-validated quit rate of 8% found in this study, we estimate that in the year 2012–13 the services supported 36,249 clients to become non-smokers for the remainder of their lives. This is a substantial figure and provides one indicator of the ongoing value of the treatment that the services provide. The study raises a number of issues for future research including (1) examining the role of electronic cigarettes (e-cigarettes) in smoking cessation for service clients [this study did not look at e-cigarette use (except briefly in the longer-term NRT study) but this is a priority for future studies]; (2) more detailed comparisons of rolling groups with other forms of behavioural support; (3) further exploration of the role of practitioner knowledge, skills and use of effective behaviour change techniques in supporting service clients to stop smoking; (4) surveillance of the impact of structural and funding changes on the future development and sustainability of SSSs; and (5) more detailed analysis of well-being over time between those who successfully stop smoking and those who relapse. Further research on longer-term use of non-combustible nicotine products that measures a wider array of biomarkers of smoking-related harm such as lung function tests or carcinogen metabolites.

Evidence based interventions recommended by NICE to use in smoking cessation services include:

Individual behavioural counselling:

This involved scheduled face-to-face meetings with a trained smoking cessation counsellor. Ideally these sessions should be weekly over at least four weeks, and combined with pharmacotherapy.

Group behaviour therapy:

This involved scheduled face-to-face meetings where people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy). Ideally these sessions should be weekly for at least four weeks, and combined with pharmacotherapy.

Pharmacotherapy:

Smoking cessation advisers and healthcare professionals may recommend and prescribe nicotine replacement therapy, varenicline or bupropion as an aid to help people to quit smoking, along with giving advice, encouragement and support, or referral to a smoking cessation service.

Expert commentary

This detailed study provides a robust understanding of why our stop smoking services are widely considered to be amongst the very best in the world. Given that a significant proportion of those who use these services stop and never smoke again, we begin to understand why the commissioning of high quality stop smoking services must be a priority. Addressing the lack of routinely collected data at one year post quit, increasing the frequency of carbon monoxide monitoring and developing an understanding of how electronic cigarettes can enhance service provision, will increase the quality and appeal of services. The results of this study show that not only do stop smoking services work they release a significant number of people from addiction to tobacco for the remainder of their lives. 

Dave Jones, Tobacco control manager, Public Health England

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