The English smoking treatment services: one-year outcomes

Transcription

1 Blackwell Sciece, LtdOxford, UKADDAddictio Society for the Study of Addictio Origial Article Eglish smokig treatmet services: oe-year outcomes Jaet Ferguso et al. The Eglish smokig treatmet services: oe-year outcomes Jaet Ferguso 1, Lida Bauld 2, Joh Chesterma 1 & Ke Judge 1 Public Health ad Health Policy 1 ad Departmet of Urba Studies 2, Uiversity of Glasgow, Glasgow, UK Correspodece to: Professor Ke Judge Public Health ad Health Policy Uiversity of Glasgow 1 Lilybak Gardes Glasgow G12 8RZ, UK Tel: Fax: k.judge@climed.gla.ac.uk RESEARCH REPORT ABSTRACT Aims To assess the impact of Eglish treatmet services o CO-validated quit rates at follow-up, to explore the relatioship betwee service-related characteristics ad socio-demographic ad behavioural factors with cessatio outcomes, ad to compare the characteristics of service users lost to follow-up with CO-validated quitters. Desig Observatioal study of admiistrative iformatio liked with survey data for 2069 recipiets of smokig treatmet services who set a quit date betwee May ad November Settig Two cotrastig areas of Eglad, Nottigham ad North Cumbria, cosistig of ie primary care trust (PCT) localities. Measuremets Routie moitorig data specified by the Departmet of Health icluded iformatio about basic demographic characteristics, postcode of residece from which a deprivatio category was idetified, ature of itervetio, ad smokig status at 4-week follow-up. These data were supplemeted with iformatio about smokig status at 52 weeks, referral pathways, relapse experieces, umber of follow-up cotact attempts, socio-ecoomic status ad smokig-related behaviours obtaied from cosetig service recipiets by treatmet advisers. Fidigs Oe user i seve (14.6%) reported prologed abstiece ad was CO-validated as a successful quitter at 52 weeks. This rose to 17.7% whe selfreport cases were icluded. Relapse rates betwee 4 ad 52 weeks were almost idetical betwee the two study areas 75%. Relapse was most likely to occur i the first 6 moths followig treatmet. Users who self-reported quittig at 4 weeks were less likely (13.7%) tha those with biochemical verificatio of smokig status at 4 weeks (25.2%) to be CO-validated quitters at 52 weeks (P = 0.004). Older users (OR 1.023; CI ), people who smoke maily for pleasure rather tha to cope (OR 1.38; CI ), ad those who were extremely determied (OR 1.58; CI ) were more likely to be quitters at follow-up, whereas those with lower socio-ecoomic status (OR 0.86; CI ), who smoked their first cigarette of the day withi 5 miutes of wakig (OR 0.73; CI ) or had aother smoker i their household (OR 0.65; CI ) were less likely. I cotrast, users lost to follow-up teded to be youger ad experieced differet referral pathways tha CO-validated quitters. Geder was ot statistically sigificatly associated with cessatio at 52 weeks ad or were ay of the key characteristics of itervetio, such as group or oe-to-oe cousellig. Coclusios These results obtaied from routie services are cosistet with those obtaied from cliical trials i relatio to abstiece at oe year. Give that a high proportio of smokers relapsed betwee 4 weeks ad 1 year it is importat that future assessmets of loger-term outcomes are coducted. However, followig-up service users may moths after a itervetio is 2005 Society for the Study of Addictio doi: /j x Addictio, 100 (Suppl. 2), 59 69

2 60 Jaet Ferguso et al. expesive, ad reasoable estimates of quit rates ca be estimated from shortterm outcomes, provided that they have bee CO-validated. Future studies should moitor outcomes from a selectio of services treatig differet groups of smokers, particularly if more is to be leared about the role of smokig treatmet services i reducig iequalities i health. KEYWORDS CO validatio, iequalities, prologed abstiece, smokig cessatio. INTRODUCTION Smokig treatmet services i Eglad have proved themselves to be successful i reachig large umbers of smokers ad achievig impressive 4-week quit rates, both self-reported ad CO-validated [1,2]. Research has show, however, that rates of resumed smokig are high at loger-term follow-up. Studies have examied relapse rates at differet poits i time, followig differet treatmet combiatios ad with differet populatios of smokers [3]. Abstiece rates at 1 year, for istace, ca vary. Studies ivolvig the provisio of brief advice from a health professioal plus icotie replacemet therapy (NRT), have reported 1-year abstiece rates of aroud 10% [4,5]. More itesive itervetios ca result i a higher proportio of logerterm quitters. Treatmet that ivolves behavioural support plus the use of pharmacological treatmets has typically achieved 20 30% cessatio rates at 1 year depedig o the precise form of itervetio [3,6 8]. What has bee observed, however, is that although iitial outcomes vary sigificatly depedig o the ature of the itervetio the relapse rate betwee studies is remarkably similar. A meta-aalysis by Stapleto [9] suggests that about two-thirds of quitters at 6-week follow-up will have relapsed by 52 weeks, irrespective of the ature of the iitial itervetio. However, a recet study of the shape of relapse curves amog utreated smokers cautios that much remais to be leared about this topic [10]. Measurig loger-term cessatio rates is difficult; the umber of service users lost to follow-up becomes higher the more that time elapses. Relatively few studies attempt follow-up beyod 1 year ad eve fewer have cotacted study participats successfully more tha 3 years followig treatmet [7,11]. The Departmet of Health iitially expected all treatmet services located i Eglish Health Actio Zoes to coduct follow-up as part of routie practice [12]. However, it quickly became apparet that, although some cliics do have a good record i this respect, geeric services as a whole did ot have the capacity to follow-up all smokers ad the requiremet was dropped i 2000, whe services were rolled out to all parts of the coutry [13]. The oly remaiig madatory moitorig required was self-reported 4-week quit rates, although services were ecouraged to collect data where possible. However, aecdotal evidece suggests that very few services have bee able to implemet effective log-term follow-up; those that have tried report low respose rates. Lack of time, resources ad admiistrative capacity meas that local services have limited opportuity to ivest i coductig ay form of research to assess loger-term outcomes. Give the absece of ay reliable moitorig data, the Departmet of Health decided to commissio a study examiig loger-term outcomes as part of the atioal evaluatio of smokig cessatio services. The study ivolved providig services i two case-study areas with additioal fiace for admiistrative support to coduct follow-up of all smokers usig the service withi a 6-moth period, ad to provide modest reimbursemet to respodets to travel to a service veue for CO validatio. DATA, MEASURES AND METHODS Data The broad aims of the study were, first, to idetify what proportio of service recipiets i the study areas had self-reported prologed abstiece [14] ad were verified by CO moitor as abstiet at follow-up. Secodly, the study aimed to relate outcomes to user characteristics at the time that a quit date was set. The research took place i Nottigham ad North Cumbria. Details of services provided i both areas are outlied i a related paper [1], which compared the characteristics of COvalidated ad self-reported quitters at 4 weeks. I this study, as there are very few o-validated/self-report quitters, the characteristics of users lost to follow-up are compared with CO-validated quitters at 52 weeks. Cliets were referred to a local smokig treatmet service where they were see by a traied adviser ad set a quit date. Most the received treatmet o a weekly basis for typically 8 weeks, either with oe-to-oe or

3 Eglish smokig treatmet services: oe-year outcomes 61 group-based behavioural support, combied with NRT or bupropio. Services collected detailed iformatio about all smokers settig a quit date betwee May ad November 2002 [1]. These data icluded iformatio about: smokig history ad level of addictio; family ad persoal circumstaces; deprivatio category ad place of residece; type, quality ad locatio of services received; ad smokig status at 4 weeks. Smokers who had set a quit date durig the 6-moth study period, had self-reported quittig at 4 weeks ad who had agreed previously to participate i the research, were ivited to take part i a review. Both services were provided with extra fudig to pay a part-time admiistrator who cotacted cliets. Cliets were iitially ivited by letter ad respoded either with a freepost respose slip or by telephoe. The umber of attempts to follow-up by telephoe was recorded. Cliets agreeig to follow-up were asked by a traied member of staff to complete a short telephoe questioaire about smokig status, what else might have helped them quit, sustai the quit or prevet relapse. Cliets were the ivited to have their self-reported prologed abstiece cofirmed by CO validatio. These cliets received a moey voucher to cover expeses ad all cliets who had successfully remaied o-smokers received a cogratulatory certificate. Cliets were cosidered lost to follow-up if they did ot respod to the iitial letter ad/ or after several telephoe calls. The questioaire material was combied with the descriptive iformatio o each user collected as part of the 4-week study [1], together with the details of treatmet ad status at 4 weeks o a MS Access database. Data supplied to the research team were aoymous. Sample Details o how the iitial sample of data for the aalysis was derived are show i Table 1. The sample of 2564 cases i row 1 represets all smokers settig a quit date i the 6-moth study period i the two case-study areas. Rows 2 4 show the effect of excludig part of the total sample from the study sample available for aalysis. For example, smokers who were employed i the occupatioal health sectio of oe of the ie primary care trusts (PCTs) were accidetally excluded from the followup o data protectio grouds. Those with o paperwork had ot bee followed-up due to a clerical error. Row 5 shows the effect of excludig cases for which the umber of valid values of persoal/service characteristics Table 1 Creatio of sample for aalysis. Sample size North Cumbria Nottigham Total excluded at this stage % remaiig excluded at this stage % remaiig excluded at this stage % remaiig 1. Origial database with quit date i 6-moth period 2. Exclude from stage 1 cases with o overall coset to research ivolvemet or icomplete postcode 3. Exclude from stage 2 uder 16-year-olds 4. Exclude from stage 3 cases ot cosetig to followup, those with occupatioal health ivolvemet or o paperwork 5. Exclude from stage 4 cases with valid value cout less tha A cout of valid values for the variables i each record (excludig those variables routiely provided to the DH) was required to be at least 21 of 28, otherwise the record was ot selected (Judge et al. 2004).

4 62 Jaet Ferguso et al. at 4 weeks was less tha 21. The total study sample of 2069 cases represets 80.7% of all those recorded by local services as settig a quit date durig the study period. Of these 2069 cases settig a quit date, 1268 selfreported as abstiet at 4 weeks (excludig quit refuted by validatio test). Measures Persoal ad service characteristics Details of the descriptive idicators used i the aalysis are show i Table 2. These cover persoal details, socioecoomic circumstaces (combied to form oe socioecoomic score), livig group, smokig history, area, PCT ad service provided. Outcomes Whe the user reported sustaied abstiece betwee their origial quit date ad 52 weeks they were ecouraged to atted the smokig treatmet veue for CO validatio. If users could ot be cotacted they were classed as lost to follow-up. No attempt was made to follow-up users at 52 weeks who were o-quitters or lost to followup at 4 weeks. For the 2069 cases settig a quit date i the 6-moth sample, smokig status at 52 weeks could the be classified ito the same four possible outcomes which applied at 4 weeks; amely CO-validated quitters (classified by self-reported prologed abstiece followed by CO validatio of abstiece at 52 weeks) ; selfreported quit without validatio ; o-quitters ; ad lost to follow-up. The percetage of validated quitters is referred to as the CO-validated cessatio rate. The same pool of dummy predictor variables, based o the iformatio show i Table 2, was used as i the 4-week study [1]. Methods First, bivariate relatioships, betwee key characteristics of the sample of 2069 cases ad CO-validated cessatio ad loss to follow-up rates, are preseted. Tests showig the sigificace of differeces i rates are determied i oe of three ways. Whe the characteristic was cotiuous or almost cotiuous, a Ma Whitey U-test was applied. Whe the characteristic was a dummy variable, a c 2 test with cotiuity correctio was used. If the characteristic had three or more discrete values but was ot approximately cotiuous, each value except the referece value was cosidered as a dummy variable i its ow right to which a c 2 test with cotiuity correctio could be applied. Secodly, the relatioship betwee CO-validated cessatio ad lost to follow-up rates ad persoal/service characteristics was ivestigated with two separate forward stepwise logistic regressio aalyses (P(i) < 0.05). I order to simplify the models, the summary measure for socio-ecoomic group was used i place of the items from which it is derived. Variables were etered i three blocks: persoal characteristics ad type of referral; type of itervetio ad PCTs; ad area (North Cumbria or Nottigham). The aalysis was repeated eterig all variables ad the usig backward stepwise logistic regressio aalysis, to see whether the model could be improved. Table 2 Persoal ad service characteristics used i the aalysis. Type of characteristic Persoal details Socio-ecoomic circumstaces Livig group Smokig history Area PCT Nottigham North Cumbria Service provided Listed characteristics Age, geder, pregat at quit date, ot white British or white Irish Socio-ecoomic group (score of 1 6 based o whether educatio fiished by 16, sigle paret, livig i reted housig, uemployed or permaetly sick/disabled, whether eligible for free prescriptios ad aged uder 60, residet i lowest deprivatio decile) Curretly livig with spouse/parter, umber of adults (icludig self) i household, umber of childre i household Time betwee wakig ad smokig first cigarette, cigarettes smoked per day, age started regular smokig, seriously tried to quit smokig i last year, ease/difficulty goig without smokig for a whole day, smokes maily for pleasure or to cope, other regular smoker i household, ayoe to support cliet to stop smokig, self-reported health over last 12 moths North Cumbria/Nottigham Broxtowe ad Huckall, City Cetral, City North, City South, Gedlig, Rushcliffe Carlisle, Ede, West Referral source, itervetio settig, type of behavioural support, pharmacotherapies

5 Eglish smokig treatmet services: oe-year outcomes 63 RESULTS Smokig status The overall smokig status of respodets from the two study areas is show i Table 3. Oe user i seve (14.6%) was CO-validated as a successful quitter at 52 weeks (the primary outcome measure), risig to 17.7% whe self-reported cases ot receivig a CO-validatio test were icluded. There were 44.7% o-quitters [icludig 0.2% whose self-reported quit was refuted by a CO 10 parts per millio (p.p.m.) test], with a further 37.5% lost to follow-up. Table 3 also shows how outcomes are crucially depedet upo whether 4-week quitters were COvalidated or simply self-reported. For example, 25.2% of 4-week CO-validated quitters were cofirmed as abstiet at 52 weeks compared with 13.7% of 4-week self-report quitters. Also the proportio lost to follow-up at 52 weeks was much bigger for 4-week uvalidated quitters. Despite may importat differeces betwee the two study areas [1] the relapse rate betwee 4 ad 52 weeks was almost idetical; approximately 75% of CO-validated quitters at 4 weeks had relapsed 1 year after settig a quit date i North Cumbria (74.6%) ad Nottigham (75.3%). Smokers who had relapsed were asked to idetify whe they had started smokig agai. Of the 83% who respoded, 39% had relapsed betwee 1 ad 3 moths followig the 4-week quit date, 29% had relapsed betwee 4 ad 6 moths, 17% betwee 7 ad 9 moths ad 15% betwee 10 ad 12 moths. Thus, more tha two-thirds of those who started smokig agai had relapsed withi 6 moths of treatmet edig. Socio-demographic circumstaces Distributios of a selectio of the descriptive characteristics related to socio-demographic circumstaces are show i Table 4, which also icludes a breakdow of CO-validated cessatio ad lost to follow-up rate by each characteristic with sigificace tests. Overall, more disadvataged socio-ecoomic groups teded to have lower cessatio rates, ragig from 17.4% for group 1 to just 8.7% for group 6. Female smokers had lower cessatio rates (12.7%) tha males (17.2%, P < 0.01). The cessatio rate icreased sharply with age (P < 0.001), with those aged 61 ad over havig almost three times as high a CO-validated cessatio rate (21.5%) as those aged (just 7.8%). Users livig with a spouse or parter had a higher cessatio rate (15.9%) tha the remaider (12.8%, P < 0.10). More tha oe smoker i three (36.1%) had childre at home, ad while those with oe had a relatively high CO-validated cessatio rate of 16.4%, partly a age effect, for those with oe or two childre the cessatio rate was 12.5%, ad with three or more childre it was oly 8.6%. While cessatio rates reduced with umber of childre (P < 0.01), loss rates icreased (P < 0.001). Smokig-related behaviour Distributios of idicators of smokig-related behaviour are show i Table 5. Users who smoked their first cigarette withi 5 miutes of wakig had lower cessatio rates (11.7%) tha those startig smokig at least 30 miutes after wakig (18.1%). Cessatio rates for users smokig maily for pleasure (19.7%) were greater tha for those smokig maily i order to cope (11.4%). The presece of aother regular smoker at home was associated with a reduced cessatio rate of 12.2%, compared to 16.5% for others (P < 0.01). Cosiderig other types of smokig-related behaviour, those respodets who started smokig aged 13 or uder had a cessatio rate of just 12.7%, while those Table 3 Creatio of log-term outcome categories from 4- ad outcomes. 4-week status CO-validated quitters Self-report quit without Lost to validatio 1 No-quitters 2 follow-up Total status % 3 % 3 % 3 % 3 % 3 CO-validated quitters Self-report quit without validatio No-quitters Lost to follow-up Total where self-report quit was refuted by a egative CO validatio test were icluded with o-quitters. 2 No-quitters iclude self-report quit refuted by CO validatio test. 3 Percetages are expressed with respect to colum totals.

6 64 Jaet Ferguso et al. Table 4 Frequecies of characteristics of smokers icludig CO-validated cessatio rates ad loss rates: socio-demographic circumstaces. Characteristic Valid values % of valid values cessatio rate (%), with sig. test 2 loss rate (%), with sig. test 2 Socio-ecoomic group 1 1 Relatively advataged Relatively disadvataged Total ***,3 37.4***,3 Geder Male ** 36.5 NS Female Total Age (years) ad over Total ***,3 37.5***,3 Curretly livig with spouse/parter Yes (*) 36.7 NS No Total Number of childre (aged 0 15) at home or or more Total **,3 37.5***,3 1 Socio-ecoomic group is a summary measure based o whether educatio fiished by 16, sigle paret, reted housig, uemployed or permaetly sick/disabled, whether eligible for free prescriptios ad aged uder 60, lowest deprivatio decile. 2 Sigificace tests: NS, ot sigificat; (*) < 0.10; * < 0.05; ** < 0.01; *** < A c 2 test was used uless otherwise stated. 3 Ma Whitey U-test. startig aged 21 or over had a rate of 16.3%. Users who seriously tried to quit smokig i the year before settig a quit date had sigificatly lower cessatio rates. Users who were extremely determied to quit smokig had somewhat higher cessatio rates (16.7%) tha others (13.6%), although this was oly sigificat at the 10% level. Smokig itervetio Distributios of items relatig to the characteristics of the smokig itervetio are preseted i Table 6. The vast majority of users received oe-to-oe support (96.9%). Those users receivig group itervetio had apparetly higher cessatio rates (18.8%) tha the remaider (14.4%), although due to the small umber ivolved the differece was statistically isigificat. Most users received either NRT oly or bupropio oly. NRT was received by 78.6% of users ad bupropio by 15.7%. Just 3.4% of cliets received both, ad oly 2.4% relied upo other methods, such as willpower or other o-pharmacological meas. There were o sigificat differeces i cessatio rates or loss rates betwee the differet types of pharmacotherapies received. Multivariate aalyses The user ad service characteristics illustrated i Table 2 ad employed i the 4-week follow-up paper [1] were used as a predictor pool i the subsequet multivariate aalyses.

7 Eglish smokig treatmet services: oe-year outcomes 65 Table 5 Frequecies of characteristics of smokers icludig CO-validated cessatio rates ad loss rates: smokig-related behaviour. Characteristic Valid values % of valid values cessatio rate (%), with sig. test 1 loss rate (%), with sig. test 1 Time after wakig that first smokes Uder 5 miutes ** 36.9 NS At least 5 ad uder 15 miutes NS 39.0 NS At least 15 ad uder 30 miutes NS 37.8 NS 30 mi ad over * 35.9 NS Total Smokes maily for pleasure or to help cope Maily for pleasure ** 32.4* About equally NS 38.2 NS Maily to cope * 40.4 NS Total Aother regular smoker i household Yes ** 38.2 NS No Total Age started regular smokig (years) 13 or uder or ad over Total (*) *,2 Whether seriously tried to quit smokig i last year Yes ** 39.2 NS No Total Extremely determied to quit Yes (*) 38.7 NS No Total Sigificace tests: NS, ot sigificat; (*) < 0.10; * < 0.05; ** < 0.01; *** < A c 2 test was used uless otherwise stated. 2 Ma Whitey U-test. Modellig CO-validated cessatio ad loss rates idividually Two separate logistic regressio aalyses were used to estimate the probabilities of CO-validated cessatio ad loss to follow-up. Predictors were etered ito three blocks: persoal characteristics ad referral source; followed by itervetio details ad PCT; ad North Cumbria/Nottigham. Oly the full models with all blocks etered are preseted here. Oly terms for which the sigificace of the chage i -2 log likelihood was less tha 5% were allowed to eter. Eterig all variables followed by stepwise regressio failed to improve upo the iitial models. The results are show i Table 7. CO-validated cessatio I the model for CO-validated cessatio, both age ad umber of adults i the home were associated with a higher cessatio rate, while a higher socio-ecoomic score was associated with lower cessatio rates. Whe the period betwee wakig ad a first cigarette was less tha 5 miutes, CO-validated cessatio rates were smaller (P = 0.023). Users who had seriously tried to quit smokig i the last year had lower CO-validated cessatio rates. Smokig maily for pleasure, rather tha to cope, icreased rates. Havig aother smoker i the household sigificatly reduced rates (P = 0.003). Those who were extremely determied to quit smokig had higher rates. Cliets i Nottigham had lower rates.

8 66 Jaet Ferguso et al. Table 6 Frequecies of characteristics of smokers icludig CO-validated cessatio rates ad loss rates: itervetio. Characteristic Valid values % of valid values cessatio rate (%), with sig. test 1 loss rate (%), with sig. test 1 Referral source Self-referral NS 37.7 NS GP NS 37.5 NS Other health professioal NS 41.3 NS Practice urse NS 41.0 NS Cosultat NS 31.5 NS Other NS 36.9 NS Total Type of itervetio Oe-to-oe NS 37.6 NS Group Total Itervetio settig (multiple choice) Primary care NS 39.4* Hospital NS 32.4(*) Work-place or educatioal establishmet NS 39.3 NS Other commuity veue * 37.4 NS All valid cases Has cliet received NRT ad/or bupropio? NRT oly NS 37.6 NS Bupropio oly NS 33.6 NS NRT ad bupropio NS 38.2 NS Other (e.g. willpower/o-pharmacological) Total Sigificace tests: NS, ot sigificat; (*) < 0.10; * < 0.05; ** < 0.01; *** < A c 2 test with cotiuity correctio was used. Apart from the terms ivolvig umber of adults ad smokig maily for pleasure, all remaiig results are cosistet with the treds idetified i the correspodig aalysis of 4-week outcomes, except that o itervetio terms etered sigificatly [1]. Loss Youger users were more likely to be lost to follow-up, the opposite result to that foud for CO-validated quitters. Whe the period betwee wakig ad first cigarette was betwee 1 ad 2 hours, users were less likely to be lost to follow-up. It is therefore likely that whe the delay is less tha 5 miutes, users would have bee more likely to be lost to follow-up, agai opposite to the result for COvalidated quitters. Also, those users who were treated i primary care settigs were more likely to be lost to follow-up. DISCUSSION This study provides evidece of loger-term cessatio rates amog users of real world smokig treatmet services. This populatio of smokers is quite differet from those treated i cliical trials, that ofte represet a carefully screeed group. The 1-year CO-validated cessatio rate of 14.6% (risig to 17.7% whe self-reported quitters are icluded) idetified here is cosistet with previous studies. The evidece-base, made up largely of results from cliical trials, has foud a cessatio rate of betwee 10% (brief itervetio plus NRT) ad 30% (itesive group support plus pharmacotherapies) at 52 weeks [3,4,15]. The type of support provided to smokers accessig Eglish smokig treatmet services ivolves more tha brief advice, but i may istaces is less itesive tha the itervetios reported i some trials. This study also supports fidigs from other research regardig relapse rates at 1 year. A meta-aalysis by Stapleto [9] reported that, irrespective of the origial itervetio, two-thirds of 6-week quitters would have relapsed by 52 weeks. This traslates to a relapse rate of aroud 75% amog 4-week quitters. This study foud that three-quarters of smokers i both study areas had relapsed by 1 year. It should be oted, however, that these relapse rates are higher tha those assumed by the recet Waless report, which suggested that 30 40% of smok-

9 Eglish smokig treatmet services: oe-year outcomes 67 Table 7 Separate models 1 for CO-validated cessatio rate ad lost to follow-up at 52 weeks for cases settig a quit date. Model 1: CO-validated quit rate 4,6 Model 2: lost to follow-up 5,7 B 2 Sig. 3 OR B 2 Sig. 3 OR Persoal characteristics Age (years) < < Number of adults, icludig self, i home Socio-ecoomic group score Smokig-related behaviour Delay betwee wakig ad first cigarette Uder 5 miutes Betwee 1 ad 2 hours Serious attempt to quit smokig i last year Smokes maily for pleasure Other smoker i household Extremely determied to quit smokig Area Nottigham Itervetio Referral source Other health professioal Itervetio settig Primary care Type of itervetio Bupropio Type of itervetio missig Sample size Each model uses logistic regressio. 2 B is the ustadardized coefficiet. 3 Sigificace relates to the chage i -2 log likelihood. 4 Female would eter the model for CO-validated quit rate with B = , Sig = 0.130, OR = 0.810, 95% cofidece iterval CIOR = Female would eter the model for lost to follow-up with B = 0.005, Sig = 0.962, OR = 1.005, 95% cofidece iterval CIOR = Group itervetio would eter the model for CO-validated quit rate with B = 0.437, Sig = 0.201, OR = 1.549, 95% cofidece iterval CIOR = Group itervetio would eter the model for lost to follow-up with B = 0.208, Sig = 0.431, OR = 1.231, 95% cofidece iterval CIOR = ers truly abstiet at 4 weeks are likely to be abstiet at oe year [16]. The form of the models for CO-validated quit rates ad lost to follow-up are quite differet. I combiatio, the fidigs led support to the covetioal assumptio that those lost to follow-up should ot be regarded as successful quitters. I a earlier paper discussig short-term outcomes [1], it was suggested that self-report quitters had similar characteristics to those who were CO-validated as successful. This study cofirms the cautioary ote associated with those fidigs. It shows that ovalidated/self-report short-term quitters are more likely tha those who were CO-validated to be either oquitters or lost to follow-up at follow-up. This raises questios about relyig o self-report data for 4- week outcomes to make assumptios regardig the loger-term impact of services. Overall, the factors that predict loger-term COvalidated cessatio are broadly the same as those that were idetified as sigificat determiats of short-term cessatio [1]. Age, socio-ecoomic status, delay betwee wakig ad first cigarette, other smoker i household ad motivatio to quit are statistically sigificat predictors. All these factors affect whether a idividual quits at 4 ad at 52 weeks. It is iterestig to speculate whether these factors represet causal effects upo cessatio rates, ad whether they could be modified to improve success rates. Older people are likely to have higher success rates due to their greater likelihood of adherig to a treatmet programme ad the smaller risk of a relapse. Also, cases with a high socio-ecoomic score (higher eed) are more likely to have lower success rates due to their less favourable social circumstaces. However, this is o argumet for targetig resources o those with greatest success rates, as it is also desirable to aim resources at youger people ad those with poor social circumstaces. Similarly, people who smoke withi 5 miutes of wakig, beig highly depedet, eed more rather tha less itesive treatmet. However, perhaps it is reasoable to target more resources o those who are highly motivated; for example, those who are extremely

10 68 Jaet Ferguso et al. determied to quit, as these cases have higher cessatio rates. The differece betwee short- ad loger-term cessatio rates, ad the loss of three-quarters of short-term quitters by 1 year, is likely to be due to a rage of factors ot idetified or measured by this study. I other words, after smokers have received the origial itervetio, life itervees ad affects whether they ca sustai their quit attempt. Chages i persoal circumstaces, levels of stress ad other life evets may cause a idividual to start smokig agai, weeks or moths after their treatmet has eded. This raises the issue of relapse prevetio ad whether services should be providig smokers routiely with help to maitai abstiece. Relapse prevetio studies so far have bee lackig i efficacy, ad more research is eeded i this area. This study did ot examie the issue of relapse prevetio specifically. However, we did obtai some basic iformatio that helps shed some light o the issue. Cliets who had started smokig agai reported that the most commo period for relapse was i the first 6 moths followig the ed of their sessios with the service. This suggests that there may ideed be some merit i ivestig i relapse prevetio programmes to support smokers i the weeks immediately followig treatmet. Eglish smokig treatmet services are ot curretly fuded to provide relapse prevetio, but if loger-term cessatio is to be maximized, this may be a fruitful area for future developmet. This study assumes that loss to follow-up is equivalet to relapse by 52 weeks. This assumptio is cosistet with other studies. Although there is ample evidece to suggest that those lost to follow-up are a quite distict group from both quitters ad o-quitters it is ulikely that may of them should be cosidered as abstiet. A secod implicatio is that, i order to achieve a reasoable respose rate, follow-up has to ivolve repeated attempts to cotact smokers ad for this reaso it is expesive. Services require dedicated admiistrative support to coduct follow-up ad should ideally be able to reimburse smokers for ay costs associated with attedig service veues for purposes of CO validatio. Give these costs it is probably ot reasoable to expect all local smokig treatmet services to collect follow-up data for all smokers. The fact that the results are so cosistet with other studies suggests that it is possible to estimate 1-year outcomes from 4-week quit rates, but these should be CO-validated rather tha self-reported quit rates. The most fruitful ad realistic way forward may be to ivest i determied efforts to moitor ad evaluate loger-term outcomes from a selectio of services o a regular basis. These services should be operatig i a rage of settigs, offerig varied itervetios (i.e. group ad oe-to-oe) ad treatig differet groups of smokers. This type of follow-up would provide reliable evidece about the most effective way of treatig icotie addictio, particularly with low-icome smokers, ad could iform service desig ad developmet i the Uited Kigdom ad beyod. Ackowledgemets This study was fuded by the Departmet of Health s Policy Research Programme. The views expressed are those of the authors ad ot ecessarily those of the Departmet of Health. We are particularly grateful for the very cosiderable assistace provided by Aliso Challeger ad Fioa Hutigto ad their colleagues i the two study areas. CONCLUSION This study has importat implicatios for future moitorig ad evaluatio of smokig treatmet services. The first clear message is that loger-term follow-up is importat. I order to make ay reasoable assumptios about the cotributio of services to reducig smokig prevalece, we eed to kow what proportio of cliets is likely to achieve abstiece beyod 4 weeks. Assessig logerterm cessatio is also ecessary if we are to lear more about socio-ecoomic iequalities i smokig ad the effect that services may have o assistig disadvataged smokers to stop. The importace of loger-term outcomes is ot ecessarily limited to 52 weeks, however. Research suggests that relapse cotiues beyod 1 year ad thus it may ot be sufficiet to base assumptios about service effectiveess o oe year outcomes. Refereces 1. Judge, K., Bauld, L., Chesterma, J. & Ferguso, J. (2005) The Eglish smokig treatmet services: short-term outcomes. Addictio, 100 (Suppl. 2), Departmet of Health (2003) Statistics o Smokig Cessatio Services i Eglad: April 2002 March Lodo: Govermet Statistical Service. 3. Alterma, A. I., Gariti, P. & Mulvaey, F. (2001) Short- ad log-term smokig cessatio for three levels of itesity of behavioral treatmet. Psychology of Addictive Behaviors, 15, Sachs, D., Sawe, U. & Leischow, S. (1993) Effectiveess of a 16 hour trasdermal patch i a medical practice settig without itesive group support. Archives of Iteral Medicie, 153, Silagy, C., Mat, D., Fowler, G. & Lacaster, T. (2001) Nicotie replacemet therapy for smokig cessatio (Cochrae Review). The Cochrae Library, 1. Oxford: Update Software. 6. Björso, W. & Rad, C. (1995) Geder differeces i

11 Eglish smokig treatmet services: oe-year outcomes 69 smokig cessatio after 3 years i the lug health study. America Joural of Public Health, 85, Carlso, L. E., Taezer, P., Koopmas, J. & Barry, B. D. (2000) Eight-year follow-up of a commuity-based large group behavioural smokig cessatio itervetio. Addictive Behaviours, 25, Grades, G., Cortada, J. M., Arrazola, A. & Laka, J. P. (2003) Predictors of log-term outcome of a smokig cessatio programme i primary care. British Joural of Geeral Practice, 487, Stapleto, J. (1998) Cigarette smokig prevalece, cessatio ad relapse. Statistical Methods i Medical Research, 7, Hughes, J., Keely, J. & Naud, S. (2003) Shape of the relapse curve ad log-term abstiece amog utreated smokers. Addictio, 99, Yudki, P., Hey, K., Roberts, S., Welch, S., Murphy, M. & Walto, R. (2003) Abstiece from smokig eight years after participatio i radomised cotrolled trial of icotie patch. BMJ, 327, Departmet of Health (1999) Smokig Cessatio Services Miimum Data Set for 1999/2000, Jue 28th Lodo: Departmet of Health. 13. Departmet of Health (2001) Smokig Cessatio Services Moitorig Guidace 2000/2001. Lodo: Departmet of Health. Available at: Hughes, J., Keely, J., Niaura, R., Ossip-Klei, D., Richmod, R. & Swa, G. (2003) Measures of abstiece i cliical trials: issues ad recommedatios. Nicotie ad Tobacco Research, 5, Royal College of Physicias Nicotie Addictio i Britai (2000) A Report of the Tobacco Advisory Group of the Royal College of Physicias. Lodo: Royal College of Physicias. 16. HM Treasury (2004) Waless Review: Securig Good Health for the Populatio. Lodo: Statioery Office.