Smoking kills - so why is it missing from death certificates?

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1 Smoking kills - so why is it missing from death certificates? Louise Restrick, integrated consultant respiratory physician, Whittington Health & Islington CCG London Respiratory Network London Senate Helping Smokers Quit Delivery Team

2 Londoners dying from smoking 2 1 in 5 deaths due to smoking

3 Smoking and respiratory deaths % deaths attributable to smoking 35% respiratory deaths attributable to smoking

4 Smoking-attributable mortality England (2013) 463,986 adult deaths aged >35 Estimated to be attributable to smoking 17% all deaths 35% deaths due to respiratory diseases 28% of all cancer deaths (inc lung cancer) 79,700 deaths 24,300 deaths due to respiratory disease 37,200 cancer deaths (inc lung cancer)

Non fatal diseases There are many medical conditions associated with or aggravated by smoking, which may not 15 Smoking-attributable mortality 2014 November 2014 Estimated percentages and numbers of

5 Non fatal diseases There are many medical conditions associated with or aggravated by smoking, which may not 15 Smoking-attributable mortality 2014 November 2014 Estimated percentages and numbers of deaths attributable to smoking in England by cause among adults aged 35 Smoking and over, 2013 statistics 7 Cancers Illness and death 2 Number of deaths All deaths % of deaths Deaths estimated to be caused by smoking Men Women Total Men Women Lung, Trachea and Bronchus 28,521 13,700 9,300 23, Introduction Oesophagus 6,324 2,900 Smoking is the primary cause of preventable illness and premature death, accounting for 1,200 4, approximately 100,000 deaths a year in the United Kingdom. Bladder Smoking harms nearly every organ of the body and dramatically reduces both quality of life and life 4,226 expectancy. Smoking 1, , causes lung cancer, respiratory disease and heart disease as well as numerous cancers in Pancreas other organs including lip, mouth, throat, bladder, kidney, stomach, liver 7,082 and cervix. The , US Surgeon General report, How Tobacco Smoke Causes Disease, concludes that there is no Upper risk-free respiratory level of exposure sites to tobacco smoke, and there is no safe tobacco 2,059 product , The World Health Organization estimates that the global yearly death toll as a result of tobacco Stomach 3, use is currently 6 million (including exposure to secondhand smoke). 3 This is expected to rise to million by 2020 and to more than 8 million a year by Kidney It is predicted that by the end of the 21st century, tobacco will have killed one billion people. 3, Larynx For every death caused by smoking, approximately 20 smokers are suf fering 649from a smoking related disease. 2,6 In England it is estimated that in , amon g adults aged 35 and over, Myeloid around leukaemia 460,900 d NHS hospital admissions were attributable to smoking, 2,495 accounting ufor 5% 300 of all hospital admissions in this age group. 7 The cost of smoking to the National Health Service in England is estimated to be 2 billion a year. Cervical Deaths caused by smoking Unspecifie Smoking is the si leading te cause of preventable death and disease in the 8,019 UK. About half 2,000 of all lifelong 900 2, smokers will die prematurely, losing on average about 10 years of life. All Cancer 134,969 Smoking kills more people each year than the following preventable causes of death combined: [figr es 23,700 for Engl and 13,500 37, except HIV which is for UK and trafficacci dent s for Gr eat Br itai n] Respiratory 10 obesity (34,100) 11 Chronic obstructive alcohol (6,490) lung disease* 12 road trafficacci dent s (1, 713) 25,597 10,300 9,600 19, illegal drugs (1,605) Pneumonia 14 HIV infection (504) 24,636 2,400 2,000 4, All Respiratory Most smoking-related deaths are from one of three types of disease: 68,891 lung cancer, chronic 12,800 11,600 24, obstructive pulmonary disease (COPD which incorporates emphysema and chronic bronchitis) Digestive and coronary heart disease (CHD). In 2013, 17 per cent (79,700) of all deaths of adults aged 35 to smoking six). 7 and over in England were estimated to be attributable Stomach and duodenal ulcer (around one in 1, Of these smoking caused: 37,200 (28%) of all cancer deaths Circulatory 24,300 (35%) of all respiratory deaths 17,300 (13%) of all circulatory disease deaths Ischaemic heart disease 59,165 5,400 2,500 7, ASH Fact Sheet on Smoking Statistics - Illness and death Aortic aneurysm Planned review date: 5,448 November ,000 1,200 3, Cerebrovascular disease (stroke) 32,274 1,600 1,100 2, Other heart disease 22,901 1,700 1,300 3, Other arterial disease 2, Atherosclerosis All Circulatory 129,968 10,900 6,400 17, All Deaths 223,249 Total caused by smoking 47,900 31,800 79,700 NB: Estimated attributable number of deaths is rounded to the nearest 100. Numbers may not all total due to rounding. *ICD codes J40-J44 which includes bronchitis, emphysema and other chronic obstructive lung disease. The proportion of deaths attributable to smoking is the median (mid-point) between the highest and lowest estimates for this group of diseases.

6 Smoking-attributable mortality NEJM 2015

7 Example: Recording smoking on death Ia. Pulmonary embolism Ib. Fractured neck of femur Tripped on loose floor rug at home certificates Ic. Examples: Ia. II. Ib. Ic. Subarachnoid haemorrhage Ruptured aneurysm of anterior communicating artery Left sided weakness and difficulty with balance since haemorrhagic stroke 5 years ago; hemiarthroplasty 2 days after fracture II. Guidance for doctors completing Medical Certificates of Ia. Intraventricular Cause of haemorrhage Death in England and Wales Ib. Warfarin anticoagulation Ic. atrial fibrillation Remember to state clearly if a fracture was pathological, that is due to an underlying disease process such as a metastasis from a malignant neoplasm or osteoporosis. From the Office for National Statistics Death Certification Advisory Group, Revised July 2010 II. 1 The purposes of death certification Planned changes to death certification Who should Substance certify the death?... misuse 3 4 Referring deaths to the coroner How to Neoplasms complete the cause of death section Sequence leading to death, underlying cause and contributory causes Results of investigations awaited Avoid old age alone Never use natural causes alone Avoid organ failure alone Avoid terminal events, modes of dying and other vague terms Never use abbreviations or symbols Specific causes of death... 9 Example: 6.1 Stroke and cerebrovascular disorders Neoplasms Ia. 6.3 Diabetes Carcinomatosis mellitus Ib. 6.4 Deaths Small involving cell infections carcinoma and communicable of left main diseases... bronchus Injuries and external causes Ic. 6.6 Substance Heavy misuse smoker... for 40 years 14 Deaths from diseases related to chronic alcohol or tobacco use need not be referred to the coroner, Malignant neoplasms provided (cancers) the disease remain a major is clearly cause of stated death. Accurate on the statistics MCCD. are important for planning care and assessing the effects of changes in policy or practice. Where applicable, you should indicate whether a neoplasm was benign, malignant, or of uncertain behaviour. Please remember to specify the histological type and anatomical site of the cancer. Example: This guidance is intended to complement the notes for doctors in the front of every book II. of MCCDs. Those instructions remain current, except for the change in lower age limit at which old age is thought to be acceptable as the sole cause of death (now 80 instead of 70, as covered in detail below). Doctors should familiarise themselves with the MCCD notes, and consult them if they are in any doubt about whether, or how, to certify a death. Hypertension, cerebral arteriosclerosis, ischaemic heart disease. You should make sure that there is no ambiguity about the primary site if both primary Ia. and hepatic encephalopathy secondary cancer sites are mentioned. Do not use the terms metastatic or metastases Ib. alcoholic unless liver cirrhosis you specify whether you mean metastasis to, or metastasis from, the named site. Ic. Examples: F66 Guidance since 1992 Ia. Carcinomatosis Ib. Bronchogenic carcinoma upper lobe left lung Ic. Smoked 30 cigarettes a day II. Chronic bronchitis and ischaemic heart disease. II. difficult to control insulin dependent diabetes

8 Recording smoking on death certificates 85% of deaths from COPD attributable to smoking 81% deaths from lung cancer attributable to smoking hospital deaths/year ~2000 deaths 18/ and 15/ ,000 lung cancer and 18,900 COPD deaths attributable to smoking England 2013 Proctor I et al Clin Pathol 2012;65:

9 Case for recording smoking on death certificates Part of established guidance for completing death certificates Enables documentation of actual, rather than attributable, impact of smoking in death statistics Changes how clinical teams think about impact of tobacco dependence and importance of smoking cessation interventions Increases family awareness of importance of smoking on health in families where other family members smoke (as recipients of the death certificate) South Africa Smoker five years ago? included on death notifications since 1998

10 Smoking and emergency medical admissions Data Sources: CQUIN data (ICE smoking assessments; ICE discharge summaries; PAS admissions) Inclusions: Patients admitted as an emergency in period who were asked if they were smokers. Smoking prevalence for Whittington Health emergency admissions in 14/15 Data Sources: CQUIN data (ICE smoking assessments; ICE discharge summaries; PAS admissions) Inclusions: Patients admitted as an emergency in period who were asked if they were smokers. Smoking status: Smoking prevalence for Whittington Health emergency admissions in 1 Smoking Prevalence : All Specialties Admission Month Smokers Patients assessed Smoking prevalence Apr % Smoking responsible for May % Jun % ~500 Jul adult 161 admissions % Aug % Sep % >1 Oct-14 million smokers treated 19.1 in % Nov % Dec % hospital Jan % Feb % 2.6 Mar-15 million episodes of care 18.1 % Smoking prevalence for Whittington Health emergency admissions in 14/15 Smoking Prevalence : All Specialties Total 1,974 9, % Data Sources: CQUIN data (ICE smoking assessments; ICE discharge summaries; PAS admissions) Admission Month >90% Smokers of admitted Patients assessed patients Smoking prevalence Inclusions: Patients admitted as an emergency in period who were asked if they were smokers. Smoking Prevalence : Thoracic Medicine Apr % May % Admission Month Smokers Patients assessed Smoking prevalence Smoking Prevalence : All Specialties Jun % Apr % Admission Jul-14 Month Smokers 161 Patients assessed 775 Smoking 20.8 prevalence % May % Apr-14 Aug % 22.6 % Jun % May-14 Sep % 19.6 % Jul % Oct % Jun % Aug % Nov % Jul % Sep % Dec % Aug % Jan % Oct % Sep % Feb % Nov % Oct-14 Mar % 19.1 % Dec % Nov-14 Total 1, , % 23.7 % Jan % Dec % Feb % Jan-15 Smoking Prevalence : Thoracic 131 Medicine % Mar % Feb-15 Admission Month Smokers 133Patients assessed762 Smoking prevalence17.5 % Total % Mar-15 Apr % 18.1 % Total May-14 1, , % 20.2 % Data extracted on 23/06/2015 Jun % Szatkowski L, Murray R, Hubbard R, et al.thorax 2015;70: Smoking Jul-14 Prevalence 22 : Thoracic Medicine %

Part of change in hospital care: Identify and treat

Sick smokers are admitted to hospitals Evidence based quit

dependence in sick smokers: Behaviour change support and

are nicotine dependent and have respiratory disease to quit

11 Part of change in hospital care: Identify and treat nicotine dependence Smoking is tobacco/nicotine dependence Sick smokers are admitted to hospitals Evidence based quit smoking is the most important treatment for nicotine dependence in sick smokers: Behaviour change support and prescribed quit smoking medication As supporting people who are nicotine dependent and have respiratory disease to quit is their key treatment effective quit smoking is our clinical responsibility

Inpatient focus on communication & behaviour change conversations Evidence: Helping people help themselves A review of the evidence considering

uk/publicatio ns/evidence-helping-peoplehelp-themselves How important is it to you to eg stop smoking?

12 Inpatient focus on communication & behaviour change conversations Evidence: Helping people help themselves A review of the evidence considering whether it is worthwhile to support self-management May 2011 Identify Innovate Demonstrate Encourage ns/evidence-helping-peoplehelp-themselves How important is it to you to eg stop smoking? On a scale of 0-10 where 0 is not at all important and 10 is very important. How confident are you that you can eg stop smoking? On a scale of 0-10 where 0 is not confident at all and 10 is completely confident.

inc smoking contribution Plan ahead for patients who are dying or at risk of dying Optimise care Treatment

13 Role of MDT Board Rounds: planning for worst, hoping for best Liaison Consultant Psychiatrist Ward Manager Consultant Physician Trainees Quit Smoking Advisor Discuss diseases responsible for admission/deterioration inc smoking contribution Plan ahead for patients who are dying or at risk of dying Optimise care Treatment Escalation Plans Address symptoms and what matters to patient and family Share information with patient and family

14 Record smoking contribution on death certificates: Consultant input into death certificates for all in hospital deaths Pack- years smoking recording in Part 1 for deaths due to: COPD, lung cancer and other smoking-attributable diseases Importance and confidence - TRAINING

15 Pack-years contribution to mortality* Malignancy Lung Larynx Oesophagus Cervical Bladder Kidney Stomach Pancreas Myeloid leukaemia Respiratory COPD Pneumonia Influenza TB Cardiovascular Ischaemic heart disease Hypertensive heart disease Cerebrovascular disease Aortic Aneurysm Atherosclerosis Diabetes Gastrointestinal Stomach/Duodenal ulcer Crohns Intestinal ischaemia Renal failure *US Surgeon General Report 2010

16 Smoking-attributable mortality in one inner London Acute Trust All in-hospital deaths April 2013 March 2014 Excluded: deaths referred and accepted by Coroner 290 deaths Mean (range) age at death 79 (37-105) years 72% (210/290) died of a disease where smoking is attributable cause 65% (161/246) patients had been smokers 44 (15%) smoking status not recorded Smoking history/pack-years recorded as contributory 9% 18/210 smoking-attributable deaths mean (range) 50 (15-115) pack-years 6 in part I - 5 COPD; 1 lung cancer; 12 in Part II Contribution of respiratory disease and smoking to in-hospital mortality Shah N, Jansen D, Restrick L ERS 2015 accepted for publication

17 Recording pack-years where smoking attributable: 5 years learning to date What is important Team belief in smoking cessation as treatment for sick smokers Team members Ask Advise Act Team training in motivational interviewing & shared decision making Consultant-leadership of death certificate content Non-judgemental pack-years works Team focus on communication - before and after death Advanced Care Planning Part of care pathway focused on identifying and treating nicotine dependence for patients & families Team belief & confidence in recording pack-years on admission and on death certificates

Helping Smokers Quit: CO4 COnversation with every patient who smokes that gives them a chance/opportunity to quit CO monitoring used by clinicians COde the intervention so we can evaluate

18 Helping Smokers Quit: CO4 COnversation with every patient who smokes that gives them a chance/opportunity to quit CO monitoring used by clinicians COde the intervention so we can evaluate effectiveness including death certification COmmission the system to do this right: so right behaviours incentivised systematically. Clinically led transformational change in healthcare provider culture

Helping Smokers Quit Clinicians adding value from every contact by treating tobacco dependence

Helping Smokers Quit Clinicians adding value from every contact by treating tobacco dependence Eg Louise Restrick London Respiratory Network Lead Integrated consultant respiratory physician On behalf of