The Scottish Government

Dear Colleague

NHS SMOKING CESSATION SERVICES

Summary

1. This letter contains further information and advice about developing and extending smoking cessation services to help people to stop smoking in line with the White Paper 'Smoking Kills' which was published in December 1998 and commitments in 'Our National Health: A plan for action, a plan for change' published in December 2000. Information on the Department's recent audit of smoking cessation activity is also provided.

2. Health Boards and Trusts should ensure that smokers who wish to give up smoking have access to local smoking cessation services which provide the required motivational support.

3. Health Boards should also put in place arrangements for monitoring and evaluating the success of their smoking cessation services.

4. Health Boards and Trusts should continue with effective programmes to prevent people, particularly children and young people, from taking up the habit.

Action

5. Health Board and Trust Chief Executives are asked to ensure that the contents of this letter and Annex are drawn to the attention of all appropriate managers and staff including Directors in Public Health, Health Promotion Managers, Consultants in Obstetrics and Gynaecology, Heads of Midwifery Services/Senior Midwives, GPs,
LHCCs, Pharmacists, Dentists, Primary Care Trusts.

6. A copy of this guidance is available on the SHOW website: http://www.show.scot.nhs.uk/

Yours sincerely
GODFREY ROBSON
Director of Policy
2nd August 2001

Introduction

1. Smoking is by far the largest preventable cause of cancer and heart disease. At present among Scots, 34% of men and 32% of women are regular smokers. Smoking is responsible for around 84% of lung cancer deaths and a third of all cancer deaths. The risk is so high that the benefit of any reduction in smoking would have a rapid impact. The Executive remains committed to helping smokers to stop smoking and encouraging others not
to start. Smoking prevention is important in achieving targets to reduce cancer and CHD and Health Boards need to strike a balance between that and cessation. This guidance in the main relates to cessation activity. The CHD Plan will be supportive of primary prevention measures such as smoking cessation and this is one of the areas being addressed by the Have a Heart Paisley Demonstration Project. The project has recently appointed 4 support workerswho will work within local community groups to offer one-to-one support and group help for those people who want to stop smoking. It is recognised that, with the help of Nicotine Replacement Therapy (NRT) products and drugs such as bupropion (Zyban), together with a smoking cessation support programme, smokers are more likely to quit smoking for good. The provision of a variety of smoking cessation services should therefore be a health
improvement priority for Health Boards and Trusts.

2. NHS MEL(1999)38 provided guidance on the provision of smoking cessation services proposed under the UK Tobacco Control White Paper 'Smoking Kills' which was published on 10 December 1998. Health Boards were invited to draw up plans to use the additional £1m included within their allocations in each of the financial years 1999/2000-2001/2002.3. In general, the smoking cessation policies outlined in 'Smoking Kills' remain valid
although there has been an important change in policy in relation to the prescribing of NRT. The Scottish Executive's continued commitment to smoking cessation services is clear and smoking cessation has been identified as a priority for investment under the Health Improvement Fund (HIF) and under the Scottish Health Plan 'Our National Health: A plan for action, a plan for change'.

4. NHS MEL(1999)38 required Health Boards to monitor and evaluate the success of their smoking cessation activities. We recently wrote to all Health Boards seeking information about cessation services, and this letter provides further guidance about this and related issues to the Service, including on NRT.

Progress against targets/monitoring

5. Since 1999, progress has been made on the range of measures set out in 'Smoking Kills' including smoking cessation services in some Health Board areas. While we would expect it to be some time before we see the benefits of the measures proposed under 'Smoking Kills' bear fruit in terms of health improvement, the latest SHS figures do suggest that smoking levels amongst adult Scots have dropped from 35% to 33% (ie the health target set for 2005). While it appears that the 2005 target has already been met it is too early to say whether this trend will be maintained. It will be important to keep the impetus going in relation to all 3 priority groups: children and young people, pregnant women and adults, particularly those from disadvantaged groups. We will be continuing to monitor and evaluate the measures to assess their impact, including through the mechanisms which exist such as
the Scottish Health Survey and Health Boards' accountability reviews.

Smoking Cessation Returns

6. The Scottish Executive Health Department wrote to all Health Boards in January 2001 seeking information about their smoking cessation services. The responses, which have beenmade available to Health Promotion Managers, show that the availability of smoking cessation services and the approaches being used such as specialist smoking cessation service, community pharmacists, and general practitioners, vary widely across Scotland. In general, most Boards have developed services which are either targeted at or reach the White Paper priority groups - pregnant women, young people and people living in deprived areas - however it was not clear from the responses how widely available specialist smoking cessation services are across Board areas. In addition not all Boards have a dedicated smoking cessation co-ordinator.

7. The responses also showed that there are a number of identified gaps in the service - community-based specialist smoking cessation service, secondary care settings such as maternity hospitals, training of staff and services for ethnic minority groups. However, most Boards indicated that they intend to extend their current services - community and pharmacy-based, admission and discharge procedures in acute hospitals. Most Boards also indicated that there is a waiting time for cessation services although few were able to quantify the average wait. At this stage, the Scottish Executive does not propose to specify the precise smoking cessation services which Health Boards should develop nor to provide a detailed service framework. However, guidance on some key issues is given below.

Access to Cessation Services

8. Against this background, all Health Boards should ensure that smokers who wish to give up smoking have access to local smoking cessation services which can provide the required motivational support. Boards should ensure that cessation intervention and support are available, that gaps in local services are addressed and that relevant staff are recruited and trained appropriately to ensure that there is a wide range of services available across all health care sectors which fully meet the needs of their population. In responding to local needs, Boards may wish to integrate community-based cessation services into general healthy living promotion. Boards will wish to consider whether there is a need to develop local guidance for all staff involved in smoking cessation.

Funding

9. To support the development of smoking cessation services there is a range of resources already available to Health Boards: Smoking Kills - £1m in each of 3 years (1999/00, 2000/01 and 2001/02) was provided as part of Boards' revenue allocations specifically for smoking cessation services and NRT which was to be targeted particularly at areas of deprivation. This funding, which the majority of Boards have indicated has been used for smoking cessation activity, is now included in Health Boards' unified budgets and will therefore continue to be available.
Health Improvement Fund (HIF) - smoking prevention and cessation was identified as a priority for investment from the £26m pa Fund which has been provided for the period 2000/01-2003/04. Information supplied by Health Boards about HIF expenditure indicates that over £750k in 2000/01 was allocated to smoking cessation developments.
Revenue Allocations - £4.4bn has been allocated for 2001-02. Health Boards have received a minimum increase of 5.5%, with an average increase of 6.5%. Indicative revenue allocations totalling £4.7bn for 2002/03 and £5.0bn for 2003/04 were announced in April. Health Boards have received a minimum indicative allocation of 6.5% with an average increase of 6.9% for 2002/03. For 2003/04, Health Boards have received a minimum indicative increase of 7.4% and an average increase of 7.8%.

10. Within the HIF resources and revenue allocations, Health Boards have flexibility to direct the appropriate level of funding required to meet smoking cessation and prevention needs within their area. There are therefore substantial resources available to Health Boards to direct at these important service areas.

Examples of Health Board Smoking Cessation Developments

• Dumfries and Galloway - Smoking Matters Service provides specialist service on a one-to-one and a group basis for smokers using motivational interviewing techniques and training for staff.
• Greater Glasgow - Smoking Concerns funds 90 Community Pharmacists in Glasgow to deliver one-to-one smoking cessation support to smokers.
• Lanarkshire - Smoking cessation service provided through primary health care in Blantyre/North Hamilton Social Inclusion Partnership.

Available Guidance/support to the Service

11. The ASH/HEBS Smoking Cessation Guidelines which were sent out to all Health Boards earlier this year provide evidence-based information on the most effective smoking cessation services. Two further pieces of guidance to complement those Guidelines - a patient's guide and a health professional's guide - are currently in development by ASH/HEBS and will be circulated in due course.

Future Developments

12. It is clear that - for the future - we need to build on the achievements made to date and to begin to set standards for smoking cessation work to ensure a consistency of approach across the country. We also recognise there is a need to develop a strategic and sustainable approach to smoking prevention and cessation in Scotland. To ensure a more consistent approach across the country, we need to make sure that those involved in delivering health improvement activity - at whichever level - are equipped with the necessary skills and expertise to deliver up-to-date evidence-based training and education on prevention. With this in mind, we are looking at what else needs to be done to support NHSScotland, local authorities, and others in efforts on tobacco control. This might include, for example, the development of national training standards for tobacco control work and what needs to be done nationally to stimulate, support and co-ordinate tobacco control activities and promote evidence-based practice. Further advice will follow.

Provision of NRT/Zyban

13. NRT products have been available on GP prescription since 30 April and on nurse prescription since 1 May. All forms of NRT have been shown to be effective in aiding individuals in stopping smoking. However, as with Zyban, the best cessation rates are achieved using a combination of pharmacological intervention to overcome nicotine
addiction and motivational support. The Executive has already written to Boards and Trusts encouraging the supply of NRT products under Patient Group Directions (PGDs). Details of the legal requirements and guidance on PGDs is set out in NHS HDL(2001)7, which issued in January 2001.

14. Zyban (bupropion) was licensed in June 2000 as an aid to smoking cessation in combination with motivational support. It is not suitable for all patients due in part to its contra-indications and drug interactions. As a prescription only medicine, its use depends on the clinical judgement of the medical practitioner concerned. Unlike nicotine replacement therapy, it is not included in the Nurse Prescribers' Formulary.

Guidance on Key Issues

15. It is important that Health Boards/Trusts ensure that appropriate health professionals raise the subject of tobacco use with patients, assess smokers' readiness to make an attempt to stop smoking and ensure that the appropriate motivation and support to help them stop is available when required.

Roles of Primary Care Sector

16. All Primary Care professionals are well placed to provide and to reinforce health education and health promotion messages on smoking cessation. Doctors and other health care professionals including nurses, dentists and pharmacists can advise smokers to give up in the course of their day-to-day contact with them for health services. This is well known to be a simple and cost-effective measure which can be improved by the use of specialist counselling and NRT or Zyban. Each of these professions has an important role to play in giving the kind of smoking cessation advice that should be provided by NHSScotland. Simple anti-smoking advice should not take long but it is important that all health care professionals give out a consistent message, assess smoking habits and provide advice to smokers on giving up on as routine a basis as possible. This is one of the key messages in the
ASH/HEBS Smoking Cessation Guidelines which provide more details of what is required.

17. All GP computer systems, including GPASS, allow the recording and updating of smoking status. Smoking status is a key component of several of the care management screens currently in use looking at clinical ffectiveness in primary care. The clinical areas include secondary prevention of coronary heart disease, non-insulin dependent diabetes, asthma and hypertension. For all of these, smoking status is important and encouraging the patient to stop smoking is crucial to improving the longer-term outcome.

18. In addition, GPs and other primary health care professionals can act as referral agents into specialist counselling services for more intensive advice and support. In particular, smoking cessation is a key area of health promotion through community pharmacies where there is robust evidence of the improved outcomes resulting from pharmacist counselling. Community pharmacists are ideally placed to provide opportunistic, patient tailored
counselling every time a smoking cessation product is either dispensed or sold whether within or outwith structured smoking cessation services.

19. Primary Care Trusts and LHCCs have a crucial role in the health needs assessment of their local population. In addition, they will be important in collaborating and co-ordinating messages around health education and health promotion including smoking cessation.

Primary Care Trusts and LHCCs could also look to working with voluntary agencies and local authorities on promoting smoking cessation. Where appropriate, smoking cessation should be considered in the context of other forms of substance misuse.

Role of Secondary Sector

20. Every hospital stay or outpatient visit should be treated as an opportunity to offer smokers help to stop. All patients should have their smoking status recorded and their readiness to quit assessed, where relevant, when they come into hospital as an inpatient, daycase or outpatient. Health professionals involved in secondary care should be trained to provide advice and appropriate cessation assistance and arrange for specialist help if required. On discharge from hospital the primary care team should follow up progress with smoking cessation and provide further cessation support if required. Boards and Trusts should ensure that appropriate smoking cessation support and training for health professional staff is available in the secondary sector and that patients are referred for specialist help if required. Boards are strongly encouraged to ensure that the appropriate investment is made for smoking cessation work in the secondary sector.

Examples of Smoking Cessation Developments in Secondary Sector

• Shetland - Smoking cessation services are offered to patients in the Maternity
  Department and the Medical Ward at the Gilbert Bain Hospital.
• Lothian - Smoking Cessation Clinic at St John's Hospital is nurse-led with referrals
  coming from a range of sources including outpatient clinics and hospital wards.

Human Resources Aspects

21. Health Promotion Departments are a source of expertise, training, information and resources for smoking cessation and can assist with the development and evaluation of prevention and smoking cessation services. Given the range of health professionals involved in smoking cessation and the ways in which the service can be provided, Health Boards should, if they have not already done so, consider the need for appointing a smoking cessation co-ordinator. In addition, Boards and Trusts will need to give careful consideration to the training requirements of the different health professionals to ensure that they have the appropriate skills. It is important that Boards and Trusts plan recruitment and training.

Advice about central support for training will follow.

Monitoring and Evaluation

22. Health Boards are required to record relevant information on their prevention and smoking cessation services and to monitor and evaluate performance particularly against the targets in the White Paper - Towards a Healthier Scotland. Other published documents against which performance can be measured are ISD Scottish Health statistics and the Scottish Health Survey. The Department will be looking at a core data set that measures
effectiveness and will provide further guidance in due course. The data set is likely to cover the following areas on specialist smoking cessation services and Boards may wish to collate information on these areas for monitoring purposes:

• Number of smokers using the service per thousand population.
• Percentage of smokers successfully completing a course of treatment.
• Percentage who have received NRT/Zyban and for how long.
• Initial one month quit rate and later 3 and 12 month quit rates.
• Number of full-time staff employed through Service per thousand population.
• Overall cost of the service as a percentage of the Health Boards/Trusts' allocatedexpenditure.
• Users' feedback on quality of services.
  

23. Health Boards will wish to note that it is proposed to undertake a further audit of smoking cessation services, similar to that undertaken in January 2001, around September 2002.