The BTS Smoking Cessation Audit 2019 - In conversation with Dr Zaheer Mangera

Wednesday, June 24, 2020

Dr Zaheer Mangera is a Respiratory Consultant at North Middlesex University Hospital NHS Trust and one of the leads for the British Thoracic Society Smoking Cessation Audit.

The latest national smoking cessation audit report from BTS has just been published when the impact of COVID-19 is still evident.

It is true that this audit report has been published at an unprecedented time for the NHS.  COVID-19 has resulted in the reconfiguration of services; some of these changes are likely to be temporary but there is the chance that others will stay with us for the longer term.  Indeed some changes to the way care is delivered may be improved by our recent experiences.

I am a respiratory consultant and I am very aware that no healthcare professionals have access to their patients in the normal way at the moment.  These truly are unique circumstances for all of us and yet I think we have a real opportunity to improve smoking cessation services.  I want all health care professionals to feel empowered to engage with all their patients about smoking.  As a community of respiratory healthcare professionals, while reviewing and recasting the services we offer, we can ensure that engaging with our patients about smoking is at the heart of what we do and is not forgotten about during the COVID recovery period or during any future spikes in infection. 

As you mentioned, many people reading this will be embarking on resuming and resetting services in the light of COVID-19.  Can you offer any advice to people in relation to treating tobacco dependence?

I think it is incredibly important to adhere to evidence-based medicine.  We know that offering help in hospitals to those dependent on tobacco is of enormous benefit and, if done well, can free up vital NHS resources and deliver substantial cost savings as outlined in the Royal College of Physicians “Hiding in Plain Sight” report on tobacco dependency (2018)    

I would like to ask my colleagues to consider the following questions:

  1. Who at my Trust has dedicated time within their job plan to develop and support smoking cessation services?
  2. Who is the person on the Trust Executive Team who will support and champion smoking cessation?
  3. Do we have a clear business case or strategy outlining the road we will take to achieve the goals of the NHS Long Term Plan in relation to smoking, namely that every smoker who spends one night or more in hospital is supported with their tobacco addiction?

The answer to these questions I hope can act as a springboard to taking the steps needed in your organisation to deliver the help our patients that smoke need.

Going back to the audit report specifically.  Can you give us a little background to this?

This is the second national smoking cessation audit BTS has completed, with data entered between 1 July – 30 August 2019.  The first BTS audit was in 2016 and we were keen to find out more about the current state of smoking cessation services.

It is true that smoking rates have fallen in recent years yet smoking is still responsible for over half a million acute hospital admissions.  We know that admission to hospital provides a great opportunity to treat tobacco dependent smokers – the audit sheds a valuable spotlight on current care and enables us to see how effectively national standards for treating tobacco dependent smokers attending hospitals have been implemented across the UK.

How was the data collected?

Data was entered by clinical audit teams, doctors, stop smoking specialists and other volunteers at each participating hospital.

We were delighted that 13,647 records were entered, and 101 NHS trusts participated.  The data set focussed on BTS and NICE standards for hospital care.

Part 1 of the audit involved screening inpatient notes, importantly we included both smokers and non-smokers.  Each hospital was asked to request a set of 100 randomly selected notes: 50 from medical wards and 50 from surgical wards, covering at least 2 different specialties.  The aim was to establish whether patients were being asked the fundamental question “do you smoke?” and if this was being appropriately recorded. This information would not be captured if notes were retrieved of smokers only. If patients were recorded as being current smokers, further questions were then asked about the services they were offered.

Part 2 looked at the smoking cessation policies and services used by the institutions at the time of the audit. Participants were requested to submit one return per hospital, unless services were combined under one trust.

What is happening now in terms of recording smoking status?

Since 2016, we know that more smokers are now being asked if they would like help with their tobacco dependence; 1 in 2 are now being asked.  However, there is a vital step before this where there is huge room for improvement.  The audit showed that just under 1 in 4 patients were not asked about their smoking status at all, similar to the 2016 audit.  If people are not even asked if they smoke, then a golden opportunity to offer those that do support to quit is missed.

We have good data on how to support people wanting help with their tobacco addiction. How are we doing meeting the national standards?

The data shows that adherence to national standards is poor.  The NHS Long Term Plan aspires to support every single smoker that spends one night in hospital.  Given the data we collected, I doubt this is achievable across the NHS.  

In order to achieve this aim, we need to ensure that sufficient numbers of staff have the training and confidence to talk about smoking behaviour with their patients and yet there hasn’t been a significant change in the number of staff trained to give advice. The results of the audit highlight the fact that we critically need more investment in smoking cessation training for NHS staff if we are to meet the aims of the Long Term Plan.

On a more hopeful note, there is better progress in terms of hospitals enforcing smoke free sites.   1 in 5 hospitals reported enforcing this measure, whereas in 2016 it was only 1 in 16.  Building a culture across the NHS where tobacco dependence is considered alongside other health priorities is vital.

Do you sense that COVID-19 has had an impact on how patients feel about stopping smoking?

This is a time when concern about health and lung health in particular has naturally been heightened and in the national focus.  We can perhaps even postulate that now may be a better time than ever offer support to our patient’s that smoke.

Many services are adapting very quickly to the new landscape and offering digital solutions for appointments and ongoing support.  That is why it is more important than ever that smoking cessation services are spoken about locally as part of everyone’s recovery plan wherever they may work.

I believe there will be opportunities for greater collaboration between secondary and primary care.  It is vitally important that we all share our practice and help to ensure tobacco dependence is at the heart of NHS services. 

There is clearly a long way to go.  Are there national initiatives that will help?

As people will remember, smoking cessation is a key priority area for the NHS Long Term Plan, published for service delivery in England.  I am hopeful that this initiative, in time will provide a renewed emphasis for improvements in services with a clear funding model to ensure services are appropriately resourced.

This is an important time for sharing best practice and collaborating with others, particularly when respiratory services are being recast.  How can we help?

It certainly is important that encourage collaboration and we would really like to hear from colleagues about how your smoking cessations services are organised, and indeed how they have changed in recent months. I am aware you have already interviewed a colleague of mine, Arran Woodhouse about the smoking cessation services he leads at Kings College Hospital, and how they are continuing through the pandemic. 


Like Dr Mangera, Respiratory Futures is keen to add more resources and case studies on smoking cessation, please get in touch at if you can help.