The Scottish Government

Dear Colleague

SMOKING KILLS: A WHITE PAPER ON TOBACCO

NEW NHS SMOKING CESSATION SERVICES

Summary

1. This letter contains information and advice about developing and extending NHS efforts to help people to stop smoking in line with the White Paper 'Smoking Kills' which was published in December 1998.

Action

2. Health Boards should draw up plans to use the money which was included within their allocation for 1999-2000 (for allocations to individual Boards see Annex B attached), to support additional smoking cessation services and for the provision of free Nicotine Replacement Therapy (NRT). Annex A attached provides more detailed guidance on the implementation of this aspect of the White Paper.

3. Health Boards should also put in place provisions to monitor and evaluate the success of their additional smoking cessation services.

Yours sincerely

KEVIN J WOODS

Director of Strategy and Performance Management

8th April 1999

ANNEX A

NEW NHS SMOKING CESSATION SERVICES

Introduction

1. The UK Tobacco White Paper 'Smoking Kills' which was published on 10 December 1998 sets out a comprehensive and coherent package of measures, with 3 clear objectives:

• to reduce smoking among children and young people;

• to help adults-especially the most disadvantaged - to give up smoking; and

• to offer practical help to pregnant women who smoke.

2. To expand NHS services aimed at helping those smokers who wish to stop, £1 million has been included within Health Board allocations in each of the next 3 financial years. The White Paper signals the Government's broad policy intentions for smoking cessation services. This includes:

• GP and others being able to refer smokers for a course of specialist counselling, advice and support;

• smokers being able to self refer;

• local services to be tailored to local needs;

• one week's free supply of NRT for those who are less well-off.

3. The importance of smoking prevention and cessation in achieving targets to reduce cancer and coronary heart disease is acknowledged in the Priorities and Planning Guidance for the NHS in Scotland 1999-2002. Health Boards are expected to set out in their HIPs the action they intend to take to measure lifestyle changes in the short term, and health gain in the medium and long term. Bearing in mind the proposals for improving Scotland's health set out in the White Paper 'Towards a Healthier Scotland' the broad principles of the Tobacco Control White Paper need to be worked up to suit Scottish needs and circumstances. This paper provides some basic guidance on the use of the money allocated for smoking cessation.

Use of Funding

4. Against this background all Health Boards should ensure access to local smoking cessation services. Smoking is disproportionately high among the more disadvantaged and they should be a priority target group for cessation services. These services should be additional to existing activity on smoking cessation. Funding for these services will be available for 3 years from 1999-2000. As a rough guide, around 20% of the funds available should be spent on the provision of free NRT. The concept promoted in the White Paper is for GPs and other health professionals to be able to refer smokers to specialist cessation services. It is recognised that smokers might also wish to self refer. Health Boards will wish to bear this in mind in determining the services to be made available. Subject to satisfactory evaluation of the new services, Boards are encouraged to consider increasing their investment in years 2 and 3 to enable further expansion of these services.

5. This funding is for the provision of smoking cessation services only and may not be used for other smoking-related issues, such as health education campaigns. It can, however, be spent on, for example, support, for smoking cessation through staff training, premises, the appointment of a specialist, dedicated smoking cessation co-ordinator, support staff, purchase of equipment, advertising of the new service or evaluation of its effectiveness.

6. Health Boards should use this opportunity to test and develop a range of services and innovative approaches to delivering smoking cessation advice and help and to use different settings to advertise the existence of NHS cessation services. Boards may decide to use funds from elsewhere in their budgets to support additional health education/health promotion initiatives to complement these new smoking cessation services.

7. As mentioned in the White Paper, a recent supplement to the journal of the British Thoracic Society, Thorax, entitled 'Smoking Cessation Guidelines and Cost Effectiveness' is recommended as a guide to developing effective services. The guidelines (a copy of which is attached for addressees) received wide professional endorsement and contain evidence-based recommendations for the primary care team, for health professionals, and for smoking cessation specialists. The section on cost effectiveness and costings considers various aspects of smoking cessation, from minimal opportunistic intervention to the provision of a service for smokers run by a professional team.

Provision of Free NRT

8. NRT products are most effective when used as an adjunct to counselling. These products are in the main Pharmacy Only 'P' medicines, ie may be supplied only under the supervision of a pharmacist. The exceptions are Nicorette nasal spray, a Prescription Only Medicine 'POM' and 2-mg nicotine gum, which is available on general sale 'GSL'. The legal restrictions on 'P' and 'POM' medicines mean that a doctor must be present to authorise supply of these NRT products to patients, or patients must obtain the products from a pharmacy. A doctor's prescription is required for Nicorette nasal spray. NHS prescription forms should not be used in these schemes. CAPOs will be able to assist Boards in setting up systems for the supply and distribution of NRT, which comply with all legislative requirements, through the new smoking cessation initiatives and on suitable arrangements for the distribution of the one week's free supply of NRT.

Eligibility for free NRT

9. The White Paper made it clear that NRT should only be supplied free of charge to those smokers least able to afford it. This means that not all smokers who present to a smoking cessation service will necessarily be eligible for free NRT. The criteria for eligibility for free NRT supplies will be the same as the criteria which apply to receipt of free prescriptions and staff working within the smoking cessation initiatives will be required to confirm which of their clients meet this requirement. This will require to be made clear in any publicity which is being given locally about the smoking cessation services available. Free prescription status is a well established mechanism for meeting the prescribing needs of financially disadvantaged individuals, and also encompasses patients with specific conditions, many of whom will particularly benefit from giving up smoking.

10. While we would normally expect the week's free supply to be given to eligible smokers in the first week, staff running the smoking cessation service may provide the free week's supply to eligible smokers at any stage during their attendance at the approved smoking cessation forum. Health Boards might wish to consider whether further discretion might be exercised to allow free NRT to be given for longer periods or on more than one occasion. Local protocols will need to address the frequency with which patients will receive free NRT and arrangements to minimise obtaining multiple free supplies.

Monitoring and Evaluation

11. Health Boards will be required to account to the Management Executive for their spending on these additional smoking cessation initiatives and to monitor and evaluate their success. In carrying out this evaluation, Boards might like to consider the following points:

11.1 how many smokers have used the service;

11.2 how many have successfully completed a course of treatment (including how many have received free NRT and for how long);

11.3 initial one-month quit rate and later 3 and 12 month quit rate;

11.4 the number of staff employed through the service (is there a dedicated, specialist smoking cessation co-ordinator?);

11.5 the overall cost of the service, including the cost of free NRT; and

11.6 users' impressions of the quality of the service provided.

Additional Funding

12. Additional funding is available in the Department's budget over the next 3 years for health education and for innovative health promotion approaches to achieving reductions in then umbers of people who continue to smoke or who take up the habit. A Working Group will be set up, with NHS representation, to consider how this money might best be used and further guidance on this will be issued in due course.

Conclusions

13. The White Paper represents a major policy development and investment commitment by the Government who will be looking for effective, cost-effective and innovative responses from the NHS.

Management Executive

April 1999

ANNEX B

ALLOCATIONS FOR SMOKING CESSATION SERVICES 1999-2000

These allocations were included in Boards' general allocations for 1999-2000.