Tobacco Control Strategy - Creating a Tobacco-Free Generation

Chapter 6 Helping People to Quit Smoking

Current Position

Giving up smoking is the biggest single thing that someone can do to improve their health. The National Institute for Health and Clinical Excellence (NICE) ranks evidence-based smoking cessation support as being amongst the most cost-effective interventions available to the NHS. There is good evidence that the combination of pharmacotherapy and structured behavioural support provided by trained staff increases the chance of quitting by up to four times, compared to trying to give up smoking without help^[34].

Over the last decade there has been significant investment in developing a strong network of NHS smoking cessation services across Scotland. This network includes: specialist smoking cessation services, comprising intensive behavioural multi-session support together with pharmacotherapy; a nationally funded community pharmacy smoking cessation service; and national telephone support, Smokeline, and support website www.canstopsmoking.com.

Since 2007, NHSScotland has supported record numbers of people to quit smoking (at one month post quit date) with numbers almost trebling from 15,309 in 2007 to 44,137 in 2011/12^[35]. Service delivery has been underpinned by robust cessation targets, with a HEAT target in place since 2008. In 2011, this was followed by a successor smoking cessation HEAT target for the period up to March 2014 which has an explicit focus, for the first time, on the inequalities disparity evident in smoking rates between the least and the most deprived communities.

Challenge

If we are to achieve our aspiration of a tobacco-free Scotland, smoking cessation services need to be of the highest possible quality. Whilst the Scottish Government will maintain current levels of investment in smoking cessation, the current economic climate makes it more important than ever to ensure this funding delivers the best possible value for money. In keeping with the ambitions of the Quality Strategy, this means delivering services that are not only safe and effective but, most importantly given the nature of the commitment we are supporting people to take, person-centred. Two-thirds of Scottish smokers say they would like to quit^[36] and it is important that the services we provide are designed to maximise people's likelihood of realising this ambition.

Approach

Whilst we are committed to providing the very best smoking cessation services we can, it is important to recognise the range of factors that contribute to someone's motivation and ability to quit, whether through a dedicated service or independently. Many of the factors and actions identified in the Prevention section of this Strategy - such as price increases, reducing the availability of illicit tobacco, social norms in relation to tobacco usage and media representation, restrictions on tobacco marketing, social marketing campaigns and wider life circumstances - are just as influential in motivating someone to quit as they are in encouraging people not to start smoking in the first place. The Scottish Government is committed to taking and supporting action that motivates smokers to quit and helps them to stay quit. There is also a role for the full range of services that impact on a person's health and wellbeing to offer support and encouragement to quit smoking.

Review of Cessation Services

From 2008-11, NHSScotland has delivered a total of 89,075 successful quits at one month against a total of 228,353 quit attempts^[37]. However, within this pattern of general improvement across the sector, there is a significant variation between NHS Boards in terms of service uptake, the efficiency and effectiveness of services and the quality of outcomes for smokers attempting to quit. An evaluation of the community pharmacy service was published in November 2011^[38] and an evaluation of the Smokeline service from the user's perspective was carried out in 2010^[39]. However, there has been no such comprehensive review of NHS Board specialist services since they were set up in the early 2000s.

Action: The Scottish Government will commission NHS Health Scotland to lead a review of smoking cessation services in Scotland. This will inform recommendations to improve the effectiveness of service provision and service outcomes, in particular among deprived groups. The Review will report by summer 2013.

Lead: NHS Health Scotland/NHS Boards

The Public Health Service (PHS) Community Pharmacy Smoking Cessation Service

The Pharmacy Smoking Cessation Service has been successful in engaging local communities to provide easy access to smoking cessation support. The proportion of quit attempts delivered via pharmacies has risen from about 44% in 2008 to 70% in 2011^[40]. A recent review of the pharmacy service recommended improvements to the smoking cessation service which will now be implemented by a national advisory group on pharmacy smoking cessation.

Action: The Scottish Government and NHS Health Scotland will continue to work closely with NHS Boards and Community Pharmacy Scotland to implement changes required to ensure service improvement.

Lead: Scottish Government/NHS Health Scotland/NHS Boards/Community Pharmacy Scotland

Inequalities-Targeted Services

The requirement to confront and reduce the inequalities that dominate tobacco usage in Scotland is made clear throughout this Strategy. Services that are tailored to the specific needs of local communities have the ability to make a decisive contribution to the inequalities gradient through focusing on the factors that are likely to motivate people to quit and overcoming those barriers that are likely to hinder that progress. This requires the increased use of co-production and asset-based models of service delivery.

There are examples of innovative practice across Scotland, such as the NHS Tayside Quit4U programme, delivered in partnership with Dundee Council, which makes use of incentives as part of a wider range of behavioural support, Carbon Monoxide (CO) monitoring and pharmacotherapy. More innovative approaches are required if we are to deliver the ambitious milestones set out in this Strategy for reducing smoking prevalence in Scotland's most deprived communities. This should also take account of socio-economic inequalities and specific population groups, such as offenders and looked after children, who also experience significant inequalities in tobacco usage compared to the rest of the population. The emerging evidence on tobacco harm reduction and effective longer-term use of licensed nicotine products may be particularly important in helping to reduce rates of tobacco use in priority groups.

Smoking rates in prison populations are particularly high. In 2011, around 76% of Scottish prisoners said they were smokers and around 46% reported that they shared a cell with a smoker. Around 56% of those who smoked expressed a desire to give up smoking^[41]. We recognise the real need to work towards protection of offenders from second-hand smoke and in the provision of effective smoking cessation services. Responsibility for smoking cessation support passed from the Scottish Prison Service to NHS Boards in 2012. NHS Boards are continuing to develop services to meet the needs of offenders who smoke in prison by providing consistent and tailored smoking cessation support and pharmacotherapies.

Action: The review of smoking cessation services will include specific recommendations on delivering services that are person-centred and that support the needs of people living in deprived areas and other groups where tobacco use plays a key role in unequal health outcomes.

Lead: NHS Health Scotland

Smoking in Pregnancy

Smoking during pregnancy is the largest single preventable cause of disease and death to the foetus and infants, accounting for a third of perinatal deaths^[42]. It also contributes to health inequalities because smoking prevalence is much higher among people living in deprived areas. The current Antenatal Access HEAT target^[43] recognises the strong link to inequalities and provides an important opportunity to ensure pregnant women are able to access the support they require.

Reducing the numbers of women smoking in pregnancy is key to impacting positively on the lives of both mother and baby. The journey beyond a baby's birth is just as important with continued postnatal smoking cessation contributing to the early years' agenda by reducing the baby's exposure to second-hand smoke and the associated health risks. A mother's desire to do the best for her child means that pregnancy offers a powerful opportunity for services to support women to quit smoking.

Action: The Maternity Care Quality Improvement Collaborative will combine a focus on improving the public health role of maternity services alongside improvements in clinical care. Its overall aim is to improve outcomes and reduce inequalities in outcomes in maternity settings in Scotland. This will include measures to improve the numbers of women who are referred to smoking cessation services and improvements in the clinical management of risks for those women who are unable or unwilling to stop smoking. Key aims of the Collaborative will be: to refer 90% of women who have raised CO levels or who are smokers to smoking cessation services; and to provide a tailored package of care to all women who continue to smoke during pregnancy.

Lead: Healthcare Improvement Scotland/NHS Boards

There is evidence that self-reported smoking is under-reported and that the true smoking figures for pregnant women may be underestimated by up to 25%^[44]. There is a need for more accessible information and wider public awareness about the risks of smoking during pregnancy and the harms of second-hand smoke to pregnant women and unborn children. The aim should be to ensure that pregnant women, wider family circles and communities are supported to reduce these risks.

Action: NHS Health Scotland will work together with health professionals and pregnant women to develop effective means of communicating the risks of smoking in pregnancy and motivating women to quit smoking and stay quit, as part of the broader strategy to reduce inequalities in maternal and infant health.

Lead: NHS Health Scotland

Given the opportunities to improve and protect the health of both mother and baby, smoking in pregnancy will remain a key strategic focus for NHSScotland. In recognising the specific role of maternity services in addressing smoking in pregnancy, it will also be important to reflect on the emerging evidence on more generic models of intervention, such as the Family Nurse Partnership and kinship groups.

We need to make best use of existing maternity services and ensure that pregnant women are fully supported to access NHS Board cessation services. Existing guidance, which reflects NICE guidance on smoking cessation, highlights both the importance of CO monitoring of pregnant women along with automatic referral to smoking cessation services combined with continuing intensive support and monitoring in increasing the numbers of women who quit during pregnancy.

Action: NHS Boards should develop systems and provide training to ensure clear and effective care pathways for smoking in pregnancy in line with current guidance. This should include CO monitoring at booking and automatic referral to smoking cessation services.

Lead: NHS Boards

Targets for Smoking Cessation

Smoking cessation services in Scotland have benefited from the focus of a national HEAT target. Modifications, such as the inequalities component reflected in the current target, have also proved effective in guiding the way in which NHS Boards design and deliver services. It will be important that any new targets continue to drive forward the inequalities agenda and community-led approach.

Action: The Scottish Government will develop a successor smoking-related HEAT target to the current target which is due to be delivered in March 2014. The successor target will specifically focus on addressing health inequalities.

Lead: Scottish Government

Health Promoting Health Service

Smoking is a major contributor to disease and needs to be considered as part of an integrated healthcare system if we are to successfully reduce disease burden. This approach is set out in the vision of a Health Promoting Health Service, with every healthcare opportunity presenting a health promotion opportunity. In CEL (1) 12 the Scottish Government has made clear that it expects staff in acute settings across NHSScotland to play an active role in encouraging and supporting patients to stop smoking with two separate outcomes required: an increase in the number of NHS premises becoming completely smoke-free; and increased availability of specialist smoking cessation support to hospital patients who are motivated to quit. These outcomes are important components of the move towards smoke-free hospital grounds by 2015, and should be supported by the provision of advice and support on managing temporary abstinence to patients.

Action: As part of the wider monitoring framework for the Health Promoting Health Service, the Scottish Government, NHS Health Scotland and NHS Boards will ensure progress in improving the level of support on managing temporary abstinence in acute settings across NHSScotland This will include offering specialist smoking cessation support and ensuring pre-admission and post-discharge care pathways.

Lead: Scottish Government/NHS Health Scotland/NHS Boards

Wider NHS Services

The Quality Strategy recognises that all health professionals have a responsibility to take a person-centred approach to improving the health of the people they care for. Identifying and supporting people who smoke through referrals to specialist smoking cessation services is a key way in which professionals can discharge those responsibilities. This applies to primary and secondary care as well as community and other care settings, and to the pathways and multi-disciplinary teams that link them. Primary care settings, including dental services, are particularly well placed to engage smokers and GPs are incentivised to record smoking status and refer onwards as appropriate.

In order to fully support our goal of an NHS which works together in real partnership to provide high quality, person-centred and effective care, it is essential that health professionals take every opportunity to address smoking and provide effective onward referral. These interactions should be guided by established good-practice principles in delivering brief interventions.

Action: Within the context of health and social care integration, NHS Boards should take action to ensure health professionals address smoking in all care settings and provide effective and person-centred referral pathways to appropriate smoking cessation support.

Lead: NHS Boards

Training

Partnership Action on Tobacco and Health (PATH) is a joint initiative between ASH Scotland, NHS Health Scotland and the Scottish Government which aims to reduce the prevalence of tobacco use in Scotland. Managed by ASH Scotland, PATH has led on a number of key developments to roll out and enhance evidence of good practice for smoking cessation services across areas of training, data collection, evaluation, prevention and cessation.

To date, PATH training has focused on core skills in smoking cessation. However, it has been recognised that these core skills are also used in other topic areas. NHS Health Scotland has been leading on the dissemination of the Health Behaviour Change Competency Framework, commissioned by the Scottish Government, which has formed the basis of Health Scotland's strategy for training involving generic health behaviour change skills. Recent developments include the launch of a suite of e-learning modules and the expectation is that a core set of skills will be formed that can be taken forward to effectively and efficiently change lifestyle behaviours. PATH has supported the generic approach through the development of training resources.

The smoking cessation review will also assess current and future needs for smoking cessation training. This will include investigating training needs and developing an outline specification that reflects the generic health behaviour change developments and identifies projected training requirements. The Scottish Government will then consider options for fulfilling this specification in autumn 2013.

Action: The review of smoking cessation services will establish future smoking cessation training needs.

Lead: NHS Health Scotland

E-Cigarettes

The Scottish Government recognises the recent increased availability and profile of e-cigarettes. It is clear that this development throws up a number of challenges. There are some concerns that e-cigarettes could be used as a gateway to tobacco use and pose problems for the enforcement of smoke-free legislation. However, there is also some evidence that if new nicotine-containing devices such as e-cigarettes were properly regulated, they could have a potentially useful role to play as an alternative to cigarettes and could have their place in helping to reduce rates of tobacco use in priority groups.

The Medicines and Healthcare products Regulatory Agency (MHRA), which is responsible for the regulation of medicines across the UK, has set up an expert working group to look at both market and scientific research on nicotine containing products and is expected to be publish its findings in Spring 2013. In addition to the MHRA report, the National Institute for Clinical Excellence (NICE) is currently developing guidelines on harm reduction in relation to smoking. This will take account of the MHRA findings and will be published in May 2013.

Action: We will await the findings of the current MHRA and NICE guidance before considering what further advice on tobacco harm reduction and the use of nicotine-containing products, such as e-cigarettes, is required.

Lead: Scottish Government