Evidence base, treatment policy and coverage in England. Ann McNeill

Transcription

1 Evidence base, treatment policy and coverage in England Ann McNeill

2 Smoking cessation support: 2008/9 43% of smokers sought help in quitting 671,259 smokers (~ 7%) set a quit date with the NHS Stop Smoking Services 33% of these had validated quit rates at 4 weeks

3 Summary England s smoking cessation strategy Evidence base Development Implementation Impact Throughput and effectiveness Reaching disadvantaged smokers National quitting behaviour

4 Evidence base to policy Mike Russell started cessation research First national evidence-based, professionally endorsed guidelines and costeffectiveness guidance produced Government White Paper, Smoking Kills Smoking treatment services established nationally National Smoking Cessation and Training Centre established 09/10 - New Government Smoking Strategy?

5 Professor Michael Russell ( ) Effectiveness of brief advice from GPs Developed a model district wide smoking cessation service Maudsley Model of treatment Russell Standard for criteria for evaluating effectiveness (West et al, 2005)

6 Smoking cessation guidelines & cost-effectiveness guidance Brought an evidence based approach to a lifestyle as addiction to tobacco not universally accepted Wide endorsement by experts, professional and voluntary bodies Evidence from Cochrane tobacco addiction reviews supplemented by more recent studies

7 Brief opportunistic advice Intervention Brief opportunistic advice from a physician to stop Target population Smokers attending GP surgeries or outpatient clinics Effect size 1 95% CI 2% 1-3% 1 The difference in >6 month abstinence rate between intervention and control/placebo in studies reported West R, McNeill A and Raw M. Thorax 2000; 55: Lancaster T, Stead L. Physician advice for smoking cessation. Cochrane Database Syst Rev 2004; 4.

8 NRT products Bupropion Atypical antidepressant Varenicline α4beta2 nicotine receptor partial agonist

9 DH Service monitoring guidance 2008

10 DH Service monitoring guidance 2008

11 Cost effectiveness guidance 20,000 15,000 10,000 5,000 Cost of saving one year of life 0 Smoking cessation Typical intervention Parrott et al, Thorax, 1998

12 National cessation strategy Smoking recognised as an addiction Combination of approaches: Wide reach, lower effectiveness all health professionals encouraged to give brief advice Smaller reach, higher effectiveness a network of smoking cessation specialist services Increase accessibility of smoking cessation medications

13 Referral patterns GPs, medical doctors Quitlines NHS Stop Smoking Services Other health professionals Self- Referral

14 Referral patterns GPs, medical doctors Training Quitlines NHS Stop Smoking Services Other health professionals Self- Referral

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16 Services Largely followed Maudsley Model 6 8 weekly sessions (group or individual) of withdrawal-oriented behavioural therapy combined with pharmacotherapy: Nicotine replacement therapies Bupropion Varenicline Combination therapies 1 week NRT free 2001 NHS prescriptions

17 NRT market Broadening indications Prescriptions OTC GSL Pharmacy

18 Cessation only Cessation & Reduction Patch Inhalator Gum Cessation, Reduction & Temporary Abstinence Microtab Lozenge Nasal spray

19 Monitoring and Evaluation: Targets set for 4 week quitters SHORT TERM SUCCESS Smoker quits for 4 weeks

20 Targets? PROS Targets raise profile within health service Monitoring encouraged feedback and improvement CONS Cause a focus on throughput rather than targeting those most in need Focused on short term successes (4 weeks) rather than long term Negative attention and fraud Targets moving to treat 5% of local population of smokers over a year

21 Monitoring and Evaluation Government commissioned a wide ranging evaluation of the cessation services Enabled implementation to be more aligned with the evidence base

22 REACH Smoker sets quit date SHORT TERM SUCCESS Smoker quits for 4 weeks LONG-TERM SUCCESS Smoker quits for 1 year 15% one year CO validated continuous abstinence

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24 Q uit ratio % % prevalence Smoking & disadvantage Very little reduction in smoking in the most deprived groups compared with higher income smokers over the last few decades Lower cessation rates among low income smokers CIGARETT E SM OKING BY DEPRIVAT ION IN GREAT BRIT AIN: GHS & M os t a fflue nt Poore s t DEPRIVATION SCORE SM OKING CESSATION BY DEPRIVAT ION IN GREAT BRIT AIN: GHS & M os t a fflue nt Poore s t DEPRIVATION SCORE Jarvis & Wardle, 2006

25 Saliva cotinine (ng/ml) d e p r e v. t c Smoking & disadvantage Clear evidence that those in lower income groups have higher nicotine exposure Saliva cotinine by deprivation in adult smokers in Britain Heal t h Sur vey f or Engl and 2001 crude adj. f or ci gs/ day DEPRI VATI ONSCORE Jarvis & Wardle, 2006

26 Services & disadvantaged smokers Disadvantaged smokers were to be priority for the services: 1 st year Health Action Zones only Spearhead Trusts 1 week s free NRT given to those most in need No guidance given

27 REACH Smoker sets quit date SHORT TERM SUCCESS Smoker quits for 4 weeks LONG-TERM SUCCESS Smoker quits for 1 year

28 Disadvantaged smokers: Reach of services 4 evaluations of NHS SSS looked specifically at effectiveness in accessing disadvantaged groups: Lowey et al 2002 Chesterman et al 2005 NEPHO 2005 Baker et al 2006 Bell et al, 2007 NICE review

29 Conclusions on reach These studies provide a body of evidence that the NHS SSS have been effective overall in reaching routine and manual groups. However, one of these studies reports that there is variation within regional services, and some SHAs have been less successful in deprived smokers than other authorities Bell et al, 2007 NICE review

30 12 sources Disadvantaged smokers: Success of services Lowey et al 2002 Bauld et al 2003 NEPHO 2005 Watt et al 2005 S Gloucestershire PCT, 2005 Baker et al annual DH bulletins on quit rates Bell et al, 2007 NICE review

31 Figure 9. Percentage of successful quitters at 4 weeks (self report) from deprived areas vs. all health authorities in England % / / / / / / 05 Deprived Health Authorities All Health Authorities Bell et al, 2007 NICE review

32 52-week cessation rate (%) 1 year CO validated quit rate by deprivation Increasing disadvantage Source: Data from Ferguson et al, 2005

33 Conclusions on success Studies provided a consistent body of evidence that people from routine and manual groups are less successful in quitting successfully at 4 weeks than other smokers (Bell et al, 2007) Dependence and socioeconomic group both independent predictors of success in 2005 evaluation of surveys (Judge et al, 2005; Ferguson et al, 2005)

34 Are services helping to reduce inequalities in health caused by smoking? Bauld et al, 2007: DH monitoring data Compared no. of smokers treated and 4 week outcomes between spearhead and non-spearhead trusts Because there were more smokers being treated, the overall result was that a higher proportion of smokers in the more disadvantaged areas reported success (8.8%) than in the more advantaged areas (7.8%)

35 Conclusions on reducing inequalities This one study found that NHS Stop Smoking Services were making a modest contribution to reducing smoking-related inequalities in health in England Bell et al, 2007 NICE review

36 Smoker aware of service Proactive case finding Smoker contacts service Accessibility REACH Smoker sets quit date SUCCESS Smoker quits for 4 weeks Retention (Effectiveness) SUCCESS Smoker quits for 1 year

37 Reaching disadvantaged smokers? Proactive identification through: primary care (case records) QOF, combining smoking with other interventions eg screening, cold calling, direct mail Social marketing approaches & tailoring Flexibility of delivery eg drop in or rolling clinics, out of hours services Flexible location (workplace) Pharmacy based smoking cessation services Dental services Lay people as stop smoking advisors Incentives Bauld, McNeill, Hackshaw & Murray 2007

38 Gibson et al, paper submitted for publication

39 Gibson et al, paper submitted for publication

40 Gibson et al, paper submitted for publication

41 Evidence based treatment and universal coverage?

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43 Percent Recall of cessation interventions in the last year by current smokers UK ONS Omnibus surveys Any Leaflets/books NRT/other drugs Doctor/other medical advice Stop smoking group Year

44 British GP attitudes to smoking interventions Vogt et al, Addiction 2005;100: Too time consuming Not effective No confidence in ability Unpleasant past experience Low confidence in knowledge Intrusion of privacy Not professional duty Percent

45 Service managers: provision of relapse prevention interventions 96 managers responded- 52% response rate Of these, 58% reported providing relapse prevention interventions Type Percentage IBC 73.2% GBC 53.6% Telephone Support 76.8% NRT 48.2% Varenicline 19.6% Bupropion 21.4%

46 Evidence based treatment and universal coverage? 671,259 smokers (~ 7%) set a quit date with the NHS Stop Smoking Services in 2008/9 33% of these had validated quit rates at 4 weeks Services ~ 74m annually Services cost ~ 74m annually Medication cost ~ 60m annually

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49 THANK YOU