Smoking Cessation Profile: Betsi Cadwaladr University Health Board 2012/2013

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1 Smoking Cessation Profile: Betsi Cadwaladr University Health Board 2012/2013 Authors: Delyth Jones, Principal Public Health Officer, Claire Jones, Public Health Intelligence Specialist & Dr Chris Stockport, Interim Assistant Medical Director & Locality Lead Date: 10 October 2013 Version: Final V3 Publication/ Distribution: Community Services Partnership Board Corporate Nursing Primary Care Improvement and Business Support Locality Leads Pharmacy and Medicines Management CPG Pharmacy and Medicines Management Locality Leads Practice Managers Primary Care Development Unit Primary, Community and Specialist Medicine CPG Primary Care Support Unit Senior Management Team (North Wales), Public Health Wales Tier 1: Smoking Cessation Project Response Group Purpose and Summary of Document: To provide an update on smoking prevalence in Betsi Cadwaladr University Health Board (BCU HB) and an overview of smoking cessation services performance for against 2013/14 NHS Wales Delivery Framework Tier 1: smoking cessation targets. To make recommendations to Locality Leads, Pharmacy and Medicines Management Clinical Programme Group (CPG) and Stop Smoking Wales (SSW) on required actions to meet the Tier 1 target in 2013/14.

2 1. Executive summary 1.1 Background To support achievement of the smoking prevalence target of 16% by 2020, the NHS Wales Delivery Framework included a smoking cessation Tier 1 target for Health Boards this year: 5% of smokers make a quit attempt via smoking cessation services, with at least a 40% CO validated quit rate at 4 weeks. This profile is the first attempt to measure Health Board achievement against this target using data. Welsh Health Survey data is used to understand the numbers of smokers who need to be treated in each unitary authority (UA) area. Stop Smoking Wales (SSW) and Pharmacy Level 3 services outcome data is used to measure achievement against the target. In addition, an attempt is made to identify the in-house smoking cessation provision offered by General Practice services as limited information is currently available on these services. This provision is estimated using smoking cessation pharmacotherapy prescribing costs from the Comparative Analysis for Prescribing Audit (CASPA), NHS Wales Business Partnership database. This analysis provides proxy estimates of activity. 1.2 Main Findings In BCU HB, 6,499 adult smokers needed to be treated to achieve the Tier 1: smoking cessation 5% target in. 4,636 adult smokers were treated by Pharmacy Level 3 services and SSW in ; this is lower than the number treated in (4,704). Twenty six percent (1,201) of smokers were treated by SSW and 74% by Pharmacy Level 3 (3,435). 3.6% of adult smokers were treated in (a fall of 0.1% since ). This does not meet the target Tier 1 target. A 40% CO validated quit rate was achieved at 4 weeks in ; this is in line with target requirement (Pharmacy Level 3 services, 39%; SSW 42%). This quit rate remained unchanged from. The percentage of smokers treated in differed between UA areas, with Denbighshire and Gwynedd achieving the 5% target. The lowest percentage of smokers treated was in Flintshire (1.9%) which does not offer a Pharmacy Level 3 service, followed by Anglesey (3.3%), Wrexham (3.3%) and Conwy (3.7%). Wrexham and Flintshire have 41% of the smoking population in BCU HB; achieving the Tier 1 target in these areas would have a significant impact on the health of this population. Date : Version: Final (V3) Page 2 of 15

3 Based on an analysis of prescribing data, it is estimated that just under 1 million pounds is spent on pharmacotherapy for smoking cessation in BCU HB by GP practices. In addition to this, funding is spent by BCU HB on pharmacotherapy for smoking cessation as an integral part of Pharmacy Level 3 services provision. It is estimated that approximately 4,600 smokers are treated annually by GP practices. Estimates based on prescribing data suggest that GP (in-house service) provision accounts for more treated smokers than SSW and Pharmacy Level 3 services combined. Despite representing the greatest component of smoking cessation pharmacotherapy costs, very little is known about the population treated by GP practices. Prescription analysis would suggest that a significant number of prescriptions are for inappropriate course lengths. The evidence base suggests that it is unlikely that GP practice smoking cessation interventions would achieve the same quit rates as specialist services, unless they are well structured with ongoing support, CO monitoring and validation. 1.3 Recommendations a) A clear pathway for smoking cessation services should be agreed and circulated. b) Take up of brief intervention training by all front line health workers in primary and community care should be encouraged. c) GP practices wishing to continue to provide in-house smoking cessation interventions should be able to demonstrate processes and competencies which are comparable to validated smoking cessation services. This includes the provision of CO monitoring. d) GP practices providing in-house smoking cessation interventions should be encouraged to provide details of number of patients treated and validated quit rates at 4 weeks. e) Resources to support practices should be targeted to those practices who appear to be outliers in the data. f) Future Pharmacy Level 3 data collection should include registered GP practice to enable this data to be added to the profiles. g) Future locations of SSW and Pharmacy Level 3 services should take into account population need at a LSOA level and consider improving equality of access for more deprived and more remote populations, including providing services within GP practices. Date : Version: Final (V3) Page 3 of 15

4 2. Introduction Reducing smoking prevalence is a key action in the Welsh Government s Tobacco Control Action Plan 1. The aim is to decrease adult smoking prevalence rates in Wales to 20% by 2016 and 16% by In April 2013 the NHS Wales Delivery Framework included a new Tier 1 performance indicator for Health Boards related to smoking cessation 2 : 5% of smokers make a quit attempt via smoking cessation services, with at least a 40% CO validated quit rate at 4 weeks. It is recognised that both local and national work is required to sustain improvement to meet the minimum 5% target, however, to reach the medium and longer term prevalence targets there is a need to exceed this target. 3. Smoking prevalence Just under a quarter (23%) of adults in Betsi Cadwaladr University Health Board (BCU HB) smoke, which is equal to the average for Wales 3. Latest data from the Welsh Health Survey shows smoking prevalence in BCU HB ranges from 21% in Gwynedd and Flintshire to 25% in Wrexham and Anglesey. Smoking prevalence in Anglesey has increased from 24% in to 25% in Proportion (%) of adults who reported being a current smoker, Wales, Betsi Cadwaladr University Health Board and unitary authorities (age standardised), and Source: Welsh Government (Welsh Health Survey) Wrexham Isle of Anglesey Wales The 2020 target for Wales is to reduce the prevalence of smoking to 16%. Adult smoking rates are highest in the most deprived areas. Denbighshire Betsi Cadwaladr UHB Conwy Gwynedd Flintshire Date : Version: Final (V3) Page 4 of 15

5 4. Current NHS Stop Smoking Services Stop Smoking Wales (SSW) offers a seven week closed group programme to smokers who are motivated to stop. It provides a combination of behavioural support and information, advice and support to access pharmacological interventions (NRT, Zyban and Champix). A one-to-one programme is offered to patients waiting for an operation, people with mental health problems and pregnant women. Telephone support is also available. Stop Smoking Wales can be contacted via telephone: or their website: Two levels of smoking cessation services are provided by community pharmacies: Level two: o Provision of NRT and additional support to clients taking part in SSW intensive behavioural support programme. o Ensure clinical suitability to NRT. Level three: o o Assess client on one-to-one basis, then start supply of appropriate NRT. Monitor use of NRT and provide ongoing advice and support. The map below shows smoking prevalence levels across North Wales; darker shading represents areas with a higher proportion of people who currently smoke. Smoking prevalence in the most deprived areas is higher than in the least deprived areas. At upper super output area (USOA), the percentage of adults who report smoking was highest in Denbighshire U002 (31%), which includes the Rhyl area and Flintshire U003 (30%) which covers the Connah s Quay and Shotton areas. Smoking prevalence is also high in areas of Wrexham, Gwynedd and Anglesey. The map also shows the locations of specialist smoking cessation services across North Wales. SSW clinics are generally located in the most populated areas of North Wales, such as Wrexham, Deeside and Rhyl; these are also some of the most deprived areas in the region. Pharmacy Level 3 services are available across North Wales, with the exception of Flintshire which has Level 2 pharmacy services. In the more rural areas of North Wales, there are fewer services for smokers to choose and access, such as southern areas of Gwynedd, Conwy and Denbighshire. Date : Version: Final (V3) Page 5 of 15

6 Smoking prevalence and smoking cessation services across Betsi Cadwaladr University Health Board* *GP practice symbols hidden under Level 3 pharmacies 5. Numbers of adult smokers needing to be treated In response to the Tier 1 smoking cessation target there is a need to understand the numbers of smokers who need to be treated in each unitary authority (UA) area. The minimum number of adult smokers needing to be treated to meet the Tier 1, 5% target was estimated by applying smoking prevalence rates from the Welsh Health Survey, to mid-year population estimates for adults aged 16 years and over. Estimates were calculated for North Wales and the six UAs for and per quarter. Wrexham has the highest number of adult smokers needing to be treated by smoking cessation services per quarter. This reflects the smoking prevalence in Wrexham, which is the highest in North Wales and the size of the adult population in the UA. Flintshire has the second highest number of adult smokers needing to be treated by smoking cessation services per quarter; this is because of the size of the adult population. These two counties combined account for 41% of the target numbers. Date : Version: Final (V3) Page 6 of 15

7 Target data: minimum number of adult smokers in North Wales who need to be treated by smoking cessation services to achieve 5% target Target numbers per years (5% of adult smokers) Target numbers per quarter (5% of adult smokers) North Wales 6,499 1,625 Isle of Anglesey Gwynedd 1, Conwy 1, Denbighshire Flintshire 1, Wrexham 1, Source: Estimated using data from Welsh Health Survey (WG), 2011 Census (ONS) 6. Performance against Tier 1 smoking target The Tier 1 smoking cessation performance indicator for 2013/14 identifies the following: 5% of smokers make a quit attempt via smoking cessation services, with at least a 40% CO validated quit rate at four weeks. BCU HB performance against this target has been monitored since 2011 and this provides a historical baseline for monitoring progress on smoking cessation activity during 2013/14 for which quarterly returns will be required against target. In, 6,499 smokers in BCU HB needed to be treated to achieve the Tier 1 target; this is higher than the number (6,394). In, 4,636 smokers were treated by Pharmacy Level 3 services and SSW; this is lower than the number treated in (4,704). 3.6% of adult smokers were treated by smoking cessation services in BCU HB in a fall of 0.1% since ; this does not meet target requirement. (This excludes in-house support provided by GP practices as this target defines the need for smokers to attempt to quit via smoking cessation services, with a CO validation at four weeks). The percentage of smokers treated in differed between UA areas, with Denbighshire and Gwynedd achieving the 5% target. The lowest percentage of smokers treated was in Flintshire (1.9%) which does not offer a Pharmacy Level 3 service, followed by Anglesey (3.3%), Wrexham (3.3%) and Conwy (3.7%). In, the 5% target was achieved by Conwy and Denbighshire. The lowest percentage of smokers treated was in Anglesey Date : Version: Final (V3) Page 7 of 15

8 (1.7%), followed by Flintshire (2%), which does not offer a Pharmacy Level 3 service, and Wrexham (2.8%). In, 1,201 adult smokers were treated by SSW (26%) and 3,435 by Pharmacy Level 3 (74%). In, 1,353 adult smokers were treated by SSW (29%) and 3,354 (71%) were treated by Pharmacy Level 3. A 40% CO validated quit rate was achieved at 4 weeks in ; this is in line with target requirement (Pharmacy Level 3 services, 39%; SSW 42%). This quit rate remained unchanged from. UA level performance against the Tier 1 target is provided in appendices one to six. Number of smokers recorded as treated by Pharmacy Level 3 Services and Stop Smoking Wales compared to Tier 1 target of 5% treated smokers, Betsi Cadwaladr University Health Board, to Source: Betsi Cadwaladr University Health Board & Stop Smoking Wales Target (1,598) Target (1,625) 949 1, Total treated smokers (Stop Smoking Wales & Pharmacy Level 3) Pharmacy Level 3 (treated smoker) Stop Smoking Wales (treated smoker) Q4 Q3 Q2 Q1 Q4 Q3 Q2 Q1 Date : Version: Final (V3) Page 8 of 15

9 Percentage of smokers CO validated quit rate at 4 weeks by Pharmacy Level 3 Services and Stop Smoking Wales, Betsi Cadwaladr University Health Board, to Source: Betsi Cadwaladr University Health Board & Stop Smoking Wales Target (40%) Pharmacy Service Stop Smoking Wales Q4 Q3 Q2 Q1 Q4 Q3 Q2 Q1 Progress against the Tier 1 target of 5% of treated adult smokers, Betsi Cadwaladr University Health Board & unitary authorities, & 2012/2013 Source: Betsi Cadwaladr University Health Board & Stop Smoking Wales 6.1 Tier 1 target = 5% BCU HB Isle of Anglesey Conwy Gwynedd *no pharmacy level 3 service in Flintshire Denbighshire Flintshire* Wrexham Date : Version: Final (V3) Page 9 of 15

10 7. Estimated numbers of patients treated by inhouse smoking cessation support in GP practices All front line health workers in Primary and Community care are expected to be able to identify smokers, and then to appropriately advise and assist them to seek support from specialist smoking cessation services. GPs and practice nurses in particular should be able to offer a brief intervention for smoking cessation. However, delivering specialist smoking cessation services is a resource-intensive evidence based behavioural program that should follow a best practice structured program and be able to achieve, and demonstrate at least a 40% quit rate at 4 weeks. It is not known how many practices in the BCUHB area have such an in-house program delivered by staff with the relevant competencies. Currently, there is no data collected on the number of smokers treated or the quit rates achieved by GP practice in-house services. There is also no reporting or quality assurance mechanism for such services, including the competencies of staff providing the service or adherence to good practice guidelines. The data presented in section 4 therefore, does not include detail of smoking cessation support provided by in-house provision in GP practices. To understand the scale of in-house smoking cessation support provided across BCU HB, it was considered that best estimates on activity could be obtained by reviewing pharmacy prescribing budget costs as a proxy for the activity of individual GP practices. Prescribing costs for NRT, Varenicline and Bupropion were obtained for each general practice in North Wales from the Comparative Analysis for Prescribing Audit (CASPA), NHS Wales Business Partnership database. The total prescribing costs of pharmacotherapy for smoking cessation for each practice were divided by , which is the average cost of smoking cessation treatment per patient; this then gave us the estimated number of patients treated. Subtracting the number of individuals treated by SSW from the estimated number of treated patients, provides the estimated numbers of people treated by GPs (in-house). This should be recognised as being a rough proxy estimate, but in the absence of reliable data to show the number of patients treated by individual GP practices, it is the only estimate possible. In addition, detail of numbers of smokers supported by Pharmacy Level 3 services is included in the tables; these prescribing costs are not included in the GP practice costs. Pharmacy Level 3 service data is currently unavailable at practice level and therefore it is not possible to distinguish whether low prescribing costs are a result of referrals to the service or whether the practice is disengaged with smoking cessation. During quarter three and quarter four,, almost 441,000 was spent on pharmacotherapy for smoking cessation by GP practice in North Wales. Based on estimated calculations this equated to around 2,756 patients prescribed with either NRT, Varenicline or Bupropion by their GP during the six month period. Of Date : Version: Final (V3) Page 10 of 15

11 these it is estimated that 2,290 (83%) of patients are treated by GPs (in-house) compared to just under 470 (17%) treated by SSW. At UA level, Wrexham has the highest pharmacotherapy costs for smoking cessation and the highest estimated number of patients treated by their GP (inhouse) rather than by SSW. This could partly be explained by Wrexham having the second largest GP practice population list size and the highest prevalence rate of smoking in the region. Total costs of expenditure on pharmacotherapy for smoking cessation by GP practice and estimated numbers of smokers treated, Betsi Cadwaladr University Health Board, q GP Practice GP practice population list size Total GP Practice Prescribing Costs (NRT, Varenicline & Bupropion) ( ) Estimated number of treated patients Actual SSW treated Estimated numbers of people treated by GPs (inhouse) Actual Pharmacy Level 3 Service treated Betsi Cadwaladr UHB + 703, ,497 1, , Anglesey UA 65,930 21, Anglesey 65,930 21, Gwynedd UA 125,990 29, Arfon 68,720 19, Dwyfor 25,180 3, Meirionydd 32,090 6, Conwy UA 116,760 25, Conwy East 54,030 9, Conwy west 62,730 15, Denbighshire UA 101,370 42, North Denbighshire 59,150 17, Central & South Denbighshire 42,220 25, Flintshire UA 148,840 34, * Deeside, Hawarden & Saltney 61,080 11, Holywell & Flint 39,060 11, Mold, Buckley & Caergwle 48,700 11, Wrexham UA 145,060 52, South Wrexham 53,130 19, West & North 40,110 14, Wrexham T own 51,820 18, Source: CASPA, NHS Wales Business Partnership & Stop Smoking Wales + Totals may not sum due to rounding * no Pharmacy Level 3 Service in Flintshire N.B Monthly data is not a subset of the quarterly data and will not sum to the quarterly totals. This is because the quarterly data is populated based on first contact being made in that quarter. For example if first contact is made in Q1, but treatment occurs in Q2, the quarterly report will show all data f or this smoker in Q1. However the monthly data will show the associated activity (such as treatment sessions) in the relevant month in Q2. Date : Version: Final (V3) Page 11 of 15

12 Total costs of expenditure on pharmacotherapy for smoking cessation by GP practice and estimated numbers of smokers treated, Betsi Cadwaladr University Health Board, q GP Practice GP practice population list size Total GP Practice Prescribing Costs (NRT, Varenicline & Bupropion) ( ) Estimated number of treated patients Actual SSW treated Estimated numbers of people treated by GPs (inhouse) Actual Pharmacy Level 3 Service treated Betsi Cadwaladr UHB + 703, ,490 1, , Anglesey UA 65,930 30, Anglesey 65,930 30, Gwynedd UA 125,990 31, Arfon 68,720 21, Dwyfor 25,180 2, Meirionydd 32,090 6, Conwy UA 116,760 28, Conwy East 54,030 10, Conwy West 62,730 18, Denbighshire UA 101,370 47, North Denbighshire 59,150 21, Central & South Denbighshire 42,220 26, Flintshire UA 148,840 40, * Deeside, Hawarden & Saltney 61,080 14, Hollywell & Flint 39,060 12, Mold, Buckley & Caergwle 48,700 13, Wrexham UA 145,060 58, South Wrexham 53,130 22, West & North Wrexham 40,110 14, Wrexham T own 51,820 21, Source: CASPA, NHS Wales Business Partnership & Stop Smoking Wales + Totals may not sum due to rounding * no Pharmacy Level 3 Service in Flintshire N.B Monthly data is not a subset of the quarterly data and will not sum to the quarterly totals. This is because the quarterly data is populated based on first contact being made in that quarter. For example if first contact is made in Q1, but treatment occurs in Q2, the quarterly report will show all data f or this smoker in Q1. However the monthly data will show the associated activity (such as treatment sessions) in the relevant month in Q2. 8. Discussion In , the percentage of adults who reported being a current smoker in BCU HB was 23%, compared to 24% in The data shows an increase in current smokers in Anglesey, from 22% in to 25% in 10-11; other UA areas in BCU HB experienced a decline or remained the same. However, there is greater variation in smoking prevalence at smaller geographical levels compared to UA and health board figures. Smoking prevalence is linked to deprivation levels; smoking rates in deprived areas of Wales rise to around 35%. At upper super output level (USOA), the percentage of adults who report smoking in the BCU HB area was highest in Denbighshire U002 (31%), which includes the Rhyl area and Flintshire U003 (30%) which covers Connahs Quay and Shotton areas. Smoking prevalence rates in these areas are statistically significantly higher than the average for Wales. Smoking prevalence rates are also high in Wrexham U002 (29%) which includes Queensway and Borras Park areas; Isle of Anglesey U001 (28%), including Amlwch and Holyhead; Gwynedd U002 (28%) including Seiont and Date : Version: Final (V3) Page 12 of 15

13 Menai (Caernarfon); and Gwynedd U001 (27%), which includes Menai (Bangor) and Hendre areas. In BCU HB, 6,499 adult smokers () needed to be treated to achieve the Tier 1: smoking cessation 5% target. Whilst the percentage of smokers treated differed between authority areas, with Denbighshire and Gwynedd achieving this target, it was not achieved across the region with only 3.6% of adult smokers treated. Wrexham and Flintshire are responsible for contributing to 41% of the target and achieving the Tier 1 target in these areas would have a significant impact on the health of its population. Further discussion is required on provision of specialist smoking cessation services in these counties to meet population needs. The numbers of patients treated by SSW decreased during whilst the numbers treated by Pharmacy Level 3 services increased; however, overall there was a decrease in the numbers treated by specialist services. A decrease was seen in the percentage of smokers treated by SSW from 29% (1,353) in to 26% (1,201) in. The 40% CO validated quit rate was achieved at 4 weeks in in line with target requirement (Pharmacy Level 3 services, 39%; SSW 42%). SSW has a higher percentage of CO validated quit rate compared to Pharmacy Level 3 services for all counties apart from in Wrexham. However, there is considerable variation in both SSW and Pharmacy Level 3 services quit rates at UA level which, if improved, could yield better outcomes. Based on the analysis of the Q3 & Q4 prescribing data it is estimated that just 1 million pounds is spent on pharmacotherapy for smoking cessation in BCU HB by GP practices. In addition to this, funding is spent by BCU HB on pharmacotherapy for smoking cessation as an integral part of Pharmacy Level 3 services provision. Q3 & Q4 expenditure on pharmacotherapy data estimates that GP (in-house service) provision accounts for more treated smokers than SSW and Pharmacy Level 3 services combined. From this data it can be estimated that approximately 4,600 smokers are treated annually by GP practices. Despite representing the greatest component of smoking cessation pharmacotherapy costs, very little is known about this population. Prescription analysis would suggest that a significant number of prescriptions are for inappropriate course lengths. However, only a small number of practices prescribing in-house smoking cessation products have formalised smoking cessation sessions, few clinicians have had formal motivational training and a minority of practices undertake CO monitoring. The evidence base suggests that it is unlikely that GP practice smoking cessation interventions would achieve the same quit rates as specialist services, unless they are well structured with ongoing support, CO monitoring and validation. The percentage of in-house smoking cessation prescribing appears high, and improved quit rates would probably occur if practices referred to specialist service provision provided by SSW and Pharmacy Level 3 services. This also Date : Version: Final (V3) Page 13 of 15

14 provides an opportunity to better quantify the number of quitters being supported. 9. Recommendations i. A clear pathway for smoking cessation services should be agreed and circulated. The pathway should: i. be seamless; ii. include both services currently delivering validated smoking cessation services (i.e. SSW and Pharmacy Level 3); iii. explain to practitioners why referral to a validated service is preferable in most circumstances; iv. be applicable to a wide audience identification and signposting of smokers to cessation services is everyone s business; v. include specific pathways for those with specific needs (e.g. pregnant women, people with severe mental health problems and those who are unable or unwilling to join a group program). ii. iii. iv. Take up of brief intervention training by all front line health workers in primary and community care should be encouraged. GP practices wishing to continue to provide in-house smoking cessation interventions should be able to demonstrate processes and competencies which are comparable to validated smoking cessation services. This includes the provision of CO monitoring. GP practices providing in-house smoking cessation interventions should be encouraged to provide details of number of patients treated and validated quit rates at 4 weeks. v. Resources to support practices should be targeted to those practices who appear to be outliers in the data in appendices one to six. vi. vii. Future Pharmacy Level 3 data collection should include registered GP practice to enable this data to be added to the profiles. Future locations of SSW and Pharmacy Level 3 services should take into account population need at a LSOA level and consider improving equality of access for more deprived and more remote populations, including providing services within GP practices. Date : Version: Final (V3) Page 14 of 15

15 10. References 1. Welsh Government, Tobacco Control Action Plan for Wales. Cardiff: Welsh Government. Available at: [accessed ] 2. NHS Wales Delivery Framework and Future Plans. Available at: [accessed ] 3. Welsh Government, Welsh Health Survey 2010 and Available at: [accessed ] Date : Version: Final (V3) Page 15 of 15