Hi Sanjay. This looks like a fascinating piece of work, but could you explain the difference between this audit and previous surveys?
BTS has done surveys on treating tobacco dependence in secondary care at least twice in last few years. They were based around some standards however they didn’t have as big a response rate. This is the first actual audit using the fantastic BTS audit tool and is based on national standards of care from NICE and BTS involving over 140 different hospitals from all over the UK and 15,000 patients, so it’s a more comprehensive piece of work.
It’s still normal to see patients and the public smoking outside hospital entrances
The outcome of the audit confirms that NICE standards, specifically PH48, as well as BTS ‘Recommendations for smoking cessation services in secondary care’, are not being met the vast majority of the time.
Some people believe smokers only have themselves to blame for on their lung-related health conditions – it’s a ‘lifestyle choice’ - and the NHS shouldn’t put more resources into these services. How can HCPs better communicate that there is value in reducing smoking-related disease in every sense of this?
We know that tobacco dependence is an addiction in the same way that people are addicted to other substances like drugs or alcohol, and many people who smoke want to stop. We should, of course, treat people in the same way we do other patients who are addicted, but often the public, patient and healthcare workers miss the fact that it’s an addiction - a medical condition - and instead treat it as a lifestyle choice.
Everything we do about tobacco in healthcare is counteracted by the massive and complex, well-funded machinery of the tobacco industry and its advertising which is very much based on lifestyle and freedom of choice. This has become ingrained in the national psyche; to change that message and de-normalise attitudes to smoking won’t happen overnight, it will take decades.
the audit found that over 50% of health trusts had no regular training for staff on how to approach patients with smoking cessation.
More positively, changes like the smoke-free ban and prohibiting smoking in cars with children have really helped. It’s also incredibly positive that the Court of Appeal has just rejected the latest appeal from tobacco firms against the government's plain packaging rules for cigarettes packs.
There is still a long way to go. For example, it’s still normal to see patients and the public smoking outside hospital entrances - how crazy is that when we know that the product they are using kills 1 in 2 users?
Can you name just 3 ‘quick wins’ that would make the greatest difference to patient outcomes (whilst maximising resources) which clinicians can focus on over the next 12 months?
The first quick-win is to ask every patient if they smoke. If they do, we should refer them to the stop smoking services automatically, as the default.
Secondly, use motivational interview techniques. Bring out the positives of why smoking cessation is done and the benefits the person will gain from it. Using negative messaging or telling them off will deter people from taking up the cessation offer. Also avoid any sort of judgement– we don’t judge people who’ve had a heart attack or have high blood pressure, but we seem to do this to smokers even when we know it’s an addiction and most want to stop.
The third quick-win is to prescribe nicotine replacement therapy to smokers who come in to help reduce the withdrawal effects from nicotine. It can often be a starting point to quitting altogether.
Is there enough joined-up thinking between primary, secondary and community care on how best to address smoking cessation sustainably? Who takes the lead and, ultimately, what will ‘success’ look like?
At the moment Public Health England commissions stop smoking services which span primary care, community, and sometimes secondary care. Unfortunately, because PHE is now part of local government which has seen more than 25% reduction in their annual budgets, many smoking cessation services have been reduced or cut altogether.
[Patients] may feel motivated to stop but no longer have any access to specialised smoking cessation treatment.
We are in a situation where patients attending secondary care, or even primary, have no service to go on to. They may feel motivated to stop but no longer have any access to specialised smoking cessation treatment. And we know very well that quitting ‘cold-turkey’, without any support, is the least successful way of giving up smoking altogether.
The best way is a combination of behavioural counselling and pharmacotherapy which is what specialised smoking cessation services provide.
Is there a consistent smoking-cessation training programme through the healthcare system?
No. In fact, the audit found that over 50% of health trusts had no regular training for staff on how to approach patients with smoking cessation. So, because staff don’t know what the best treatment is, what’s available in their hospitals, or how best to approach a patient, they often just don’t do it.
We are so far back from where we need to be, despite it being such a quick win. We could make such a difference; there’s a huge gulf between where we are and where we need to be in terms of the services available and also training HCPs, not to mention automating referral to stop smoking services.
Could you share any good examples where trusts have implemented a sustainable smoking-cessation programme?
The Whittington Hospital in north London has devised a system where every patient’s smoking status is known and recorded. It makes sure those patients are referred, that there’s an adequate funding model to pay for that service and that there is the motivation and organisation to do it.
This model proves that what we’re talking about isn’t beyond the realms of possibility, but you have to have the right leadership to achieve it. All too often, as is shown in the audit, there is no smoking cessation service in a hospital and often no medical leadership at all or no one in charge of it. It would be unthinkable not to have a lung cancer or heart attack service, but apparently it’s acceptable not to have a smoking cessation service.
How do STPs factor in this?
Many regions have already come up with their priorities for the next two years. I think there’s a recognition that they need to do more with prevention but we don’t yet know whether the STPs overall will result in more investment in prevention on tobacco.
We must keep stressing the economics to get our point across. For every £100 that’s spent on health, £97 is for the treatment of acute or chronic disease, and only £3 of the entire budget is spent on prevention, be that alcohol, tobacco or other issues related to prevention.
So everyone working on prevention has to compete for that 3%.
Of course you’d much have less acute or chronic disease if you spent more on prevention. The metaphor I use is that we keep on paying to repair damage from the car crash but we don’t spend any money on traffic lights to prevent it happening in the first place.
What steps will you be taking to use findings from the current Audit in the next version in 2-3 years’ time. And, given what you know now, is there anyone else you would like to involve next time?
We’ve made a number of recommendations as a result of the audit that would address some of the poor results we found across the country. If implemented, these will have an impact on what we find next time.
The difference between the previous surveys and this audit is that once you’re on the BTS audit programme and there’s good take up, we repeat it in 3-4 years. We have now hopefully ingrained this in the tobacco audit so we can keep taking steps to improve care for this long neglected group of patients who are addicted to tobacco.
Thank you, Sanjay.
Related reading: BTS Report ‘Smoking cessation: policy and practice in NHS hospitals’