NHSE has published a tobacco dependence treatment service delivery model, with the following expectations:

-Smoking status is recorded for every patient admitted to hospital (acute and mental health sites) and pregnant women 

-An immediate opt-out referral for an in-house discussion with an appropriately trained tobacco dependence advisor 

-Early access to appropriate pharmacotherapy, and  a personalised plan to support patients to quit smoking tobacco both whilst in contact with NHS services and beyond discharge 

Can you recommend any national reports that support the argument for treating tobacco dependence?

-Royal College of Physicians:Hiding in plain sight: Treating tobacco dependency in the NHS 
-NICE guideline [NG209]: Tobacco: preventing uptake, promoting quitting, and treating   dependence 
-Ottowa Model for Smoking Cessation 
-Cancer Research UK 
-The Khan Independent Review (2022) 

Integrated care systems (ICSs) are partnerships that allow organisations that deliver healthcare services across an area to meet, plan and coordinate services in a way that improves population health and reduces inequalities.

Integrated care is about giving people the support they need, joined up across local councils, the NHS, and other partners.

Refer to Step two of the Tobacco Dependency Roadmap.

The identification of an executive sponsor, from within the trust, to endorse the programme would be a key partner to engage with as soon as possible. Also, local, and regional stakeholders from the ICS and local authority within the Prevention and Health Inequalities Group need to be identified.

More information is available in the first session of our first webinar series (S01-01).

What is an Office for Health Improvements and Disparities (OHID) Regional lead?

How do I find the right partners?

It can be difficult to juggle the strategic and operational challenges simultaneously.  It can really help to have support to navigate the political and strategic landscape at a national, regional, and local level as well as winning hearts and minds of those who enable the programme locally. Aim to connect with colleagues working nationally to benefit from their expertise in latest national guidance, best practice, and funding opportunities. 

Answer provided by Claire Parker, Health and Wellbeing Programme Manager at the Office for Health Improvement and Disparities, Department of Health and Social Care

What more can we do to improve access to specialist help? Our local services are patchy and if we have great conversations in hospital, get a yes to a referral and prescribe NRT but then there is insufficient ongoing support, we are still failing our patients.

There can be a difference in localities as to what is available to your patients following discharge. However, the community pharmacy smoking cessation support (SCS) has been implemented and there should be several local pharmacies that provide on-going support. It is worth checking whether the local stop smoking service provide support and you could consider signposting to the digital apps available too. 

https://www.england.nhs.uk/publication/advanced-service-specification-nhs-community-pharmacy-smoking-cessation-service/ 

https://www.nhs.uk/better-health/quit-smoking 

Yes, for the first time, funding for the implementation of treatment services within a trust has been made available. NHSE has provided funding, which has been distributed to each ICS. Individual trusts can apply for this funding to set up and run a dedicated in-house treatment service.

More information is available in the first session of our first webinar series (S01-01).

Respiratory Futures has a dedicated page for tobacco dependency resources and provides a road map which guides you through the process of planning and setting up a tobacco dependency programme in an acute trust. https://www.respiratoryfutures.org.uk/programmes-pages/delivery-of-care/tobacco-dependency-project/tobacco-dependency-project-resources/tobacco-dependency-programme-roadmap/ 

ASH (Action on Smoking and Health) also provide a toolkit that include the process of accessing funding via your local ICB (Integrated Care Board) Overview: Developing a system-wide tobacco control programme - ASH 

BTS works collaboratively with national key stakeholders and organisations alongside its membership to ensure that treating tobacco dependency in community settings is recognised, supported, and promoted. 

Improving access to smoking cessation services in GP services and pharmacies, despite funding cuts, is still very much a national and local priority and the key is to remain persistent and visible to ensure this continues.   

We have a suite of resources on our dedicated section for Tobacco Dependency treatment that can be found on Respiratory Futures.

In the past, we have always talked about smoking cessation which emphasises the need for an individual to change their behaviour. However, tobacco use causes the user to develop a dependency which can be identified as a clinical relapsing condition thus requiring medical management and treatment using a system led, opt out, evidence-based pathway.

Identify a trust clinical champion, someone who may already be a visible advocate for tobacco dependency. Buy-in from a clinician is key to supporting and driving the programme forward and will ensure that members of senior management are engaged and included in the discussions from the beginning.

Next steps would be to form a trust prevention board and recruit a project manager who will then implement all aspects of the programme and will work alongside the trust clinical champion.

Key tasks to help you with this can be found in Step 2 of our Road Map.

I would say that identifying and bringing key stakeholders together from the very beginning is fundamental to the success of this programme. 

Understanding that part of the long-term success of the programme is around facilitating a shift in culture is also key. This is a journey, so persistence and patience are necessary, however having both clinical and executive leads who can advocate and support the programme amongst their peers will expediate and enhance the process. 

Answer provided by Claire Parker, Health and Wellbeing Programme Manager at the Office for Health Improvement and Disparities, Department of Health and Social Care

The National Centre for Smoking Cessation and Training (NCSCT) delivers training and assessment programmes for local and national providers of tobacco dependence services. Full details are on their website.

The following e-learning modules have been developed by individual areas which are available for anyone to access for free.

-CURE Project, Manchester

-South Yorkshire and Bassetlaw QUIT Programme

E-learning can be accessed via the NCSCT (National Centre for Smoking Cessation Training). This free training provides the opportunity to undertake VBA (Very Brief Advice) alongside more in-depth and specific skills training to support the implementation of the long term plan tobacco dependency treatment programme - https://www.ncsct.co.uk/index.php 

For the most up-to-date information on available programmes and training in your region, it is best to check with local government authorities and professional organisations in your area. 

British Thoracic Society is running a short course this coming December aimed at all healthcare professionals with an interest in, or working in, treating tobacco dependency. We hope that the course will attract respiratory registrars, tobacco dependence advisors, specialist nurses, physician associates, other doctors in training, physiotherapists. It will be delivered by a faculty of experts entirely on a virtual platform. For more information and to book a place use the link provided - https://www.brit-thoracic.org.uk/education-and-events/bts-short-courses/treating-tobacco-dependence-2023/ 

Working with colleagues in your IT department from the outset will allow you to plan data collection tools which enable you to:

-Identify patients who smoke as soon as they are admitted to ensure they receive prompt treatment and support

-Measure the impact of your service against set outcomes

More tips and information are available in session four of our second webinar series (S02-04).

Some trusts are still at the stage of working this out as there appears to be a large disparity of systems used to capture data across the country. 

There are further changes to the national collection data due, but these will be kept to a minimum and will be expected to go live from June 2023. These updates are necessary to ensure accurate data capture reflects the work carried out and to provide evidence to ensure sustainability and funding of the programme in the future. 

We have featured data collection in our past series of webinars, use the link below – see Series two, session four for the recording and to view the accompanied presentations. 

https://www.respiratoryfutures.org.uk/programmes/tobacco-dependency-project/tobacco-dependency-project-training-and-education/past-events/ 

Research, trials and locally planned quality improvement projects drive changes that impact patient care. It is worth talking to the research lead or a quality improvement (QI) lead in your Trust as they will have a list of projects that are in progress.  

If you would like to share a QI project that you are currently involved in we would love to hear from you. Alternatively, you may wish to submit an abstract to our up-coming Summer Meeting in June 2023  BTS Summer Meeting (brit-thoracic.org.uk) 

If you are new to the NHSE data dashboard, you will require access to two areas to view the dashboard. You will first need to access the NHS Prevention Programme workspace on FutureNHS, and request access to the Tobacco section  Register on FutureNHS  

Then, to access the dashboard, you will also need an NHSE Applications (OKTA) login Register on NHSE Applications 

If you have any questions or issues, you can contact england.tobacco-prevention@nhs.net, who can also provide access on request.  

There is also a comprehensive Tobacco Data Area on NHS Futures. 

If you are looking for further data resources, you can still view the recording of our previous webinar “How do I collect data to evaluate whether my service is delivering the right thing?”. The recording and slides can be accessed here.

In our TDP Training and Education section, you can view a demo of the NHSE data dashboard and watch a webinar about data collection.

More information on the steps involved, and practical examples of tools and protocols can be found in Step three of the Tobacco Dependency Roadmap.

Your service will ideally have a specific project manager, and tobacco dependence advisors. There is more information, including sample job descriptions in Step five of the Tobacco Dependency Roadmap.

There are currently no electronic cigarettes available to prescribe on a hospital formulary. Some NHS Mental Health trusts do issue vapes to patients; however, this would require the provider to go through procurement using non-tobacco companies. Many trusts across the country are taking part in local research exploring the use of e-cigarettes so it may be worth finding out if this is available in your area. 

The trust should also ensure that they have a Smoke Free policy to include a position on vaping – see link for an example of a template Service Delivery | Respiratory Futures - working together for better lung health 

Other options available to the patient are as follows – 

- Many Local Authority Stop Smoking Services can issue vapes or vouchers to exchange once they’re supported within the community. 

Patients could source their own vape on discharge following advice from their TDA on choosing the most appropriate device and by using a reputable supplier. 

We are aware that this is already happening across the country and that there may be a need for this as the programme progresses and demand increases. There are several factors to consider which will depend largely on available funding and sufficient staffing. 

If you already provide this extended service, please do let us know so that we can share your knowledge and experience.  

There has been a recent trial looking at the provision of support to patients waiting in ED called the CoSTED (Cessation of Smoking Trial in Emergency Departments) see link for more details – 

 https://www.uea.ac.uk/groups-and-centres/addiction-research-group/costed-trial 

As services develop, there may be a need to review how the offer is extended to patients who are not formally admitted but spend a significant period of time in the acute setting and would benefit from tobacco dependency treatment.  

The on-going support from hospital at home and other community support services could be considered.  

We would be pleased to hear from you if you have examples of work that you may have carried out, or indeed be planning in this area. 

Tobacco Dependency Advisors (TDAs) are healthcare professionals trained in behavioural support. They provide evidence-based behaviour change support to patients with a tobacco dependency. They are also experts in how to advise patients (and health professionals) on the use of medications and other interventions to treat tobacco dependence.  

We recognise that banding will vary locally, however the Long Term Plan payment model is based on band 3 or 4 (NHS pay scale). Local government banding may differ due to a different pay scale structure. Many trusts may choose to employ higher banded team members with greater responsibilities. 

Factors to also consider consist of the following –  

- Sufficient skill mix 

- Role and responsibilities (consider TDAs working across in-patient and community services) 

- Budget/Funding available  

- Quality  

- Expectations of duties to be carried out within the service provided.  

- Flexible working – weekends/evenings 

Step five of our Road map includes job descriptions for each banding, see link -  

https://www.respiratoryfutures.org.uk/programmes/tobacco-dependency-project/tobacco-dependency-project-resources/tobacco-dependency-programme-roadmap/ 

Local Community pharmacies now offer support, to find out more see link,  

- NHS England » NHS community pharmacy smoking cessation service  

To find out more about the pharmacies in your locality see link,  

- National Dashboard V2.0 - MLCSU Medicines Management and Optimisation Services (midlandsandlancashirecsu.nhs.uk) 

There are several digital services that can provide support via an application on a smartphone, tablet or PC – suggested ones are below 

- Quit smoking - Better Health - NHS (www.nhs.uk) 

 - Smoke Free – The help you need to quit for good (smokefreeapp.com) 

Some hospital trusts are providing their own on-going treatment with an in-house service, provided by the Tobacco Dependency Advisors that have supported the patients from admission and ideally place to offer continuing support. 

We would encourage Trusts to implement NHS Tobacco Treatment Services as new clinical pathways that are systematic, routine and embedded into day-to-day practice.  In order to do this, strong vocal leadership is key.  Likewise strong commitment from senior leaders across the ICB is an essential measure for success.  We would encourage systems to not just consider treating tobacco dependence in isolation but ensuring through collaboration with local government, a system wide approach including wider tobacco control, to achieving the smokefree ambition and reducing smoking prevalence to less than 5% across all populations. 

Remember the reasons we are working to deliver this programme. These new pathways of care have the very real potential to improve and save lives and support the sustainability of the NHS.  When things get challenging it’s helpful to sit back and reflect on this. 

Answer provided by Claire Parker, Health and Wellbeing Programme Manager at the Office for Health Improvement and Disparities, Department of Health and Social Care

Perhaps the most significant challenges we face are the long-standing cultural barriers to treating tobacco dependence in NHS settings.  Commissioning Stop Smoking Services has been the remit of local authorities for almost a decade. There is no magic bullet for this, but it is important to identify, bringing together, and support key stakeholders to fully understand the context and rationale behind the programme and to help them secure traction at both operational and strategic levels within ICB and trust level is key.  

Answer provided by Claire Parker, Health and Wellbeing Programme Manager at the Office for Health Improvement and Disparities, Department of Health and Social Care

It's important to remember that tobacco dependency treatment should be individualised to the patient's needs, therefore the time required to assess an inpatient for tobacco dependency treatment will vary depending on several factors, such as the patient's individual circumstances, the level of their tobacco dependence, their willingness to engage in treatment, and the specific assessment methods used by healthcare professionals. 

Typically, an initial assessment for tobacco dependency treatment involves gathering information about the patient's smoking history, patterns of tobacco use, previous quit attempts, and any underlying medical or psychological conditions that may impact their ability to quit smoking. The assessment may also include evaluating the patient's readiness to quit, level of nicotine dependence, and potential barriers to quitting. 

On average, a comprehensive initial assessment for tobacco dependency treatment may take anywhere from 15 minutes to an hour. However, follow-up assessments and ongoing treatment sessions may require less time, especially as the patient progresses through their tobacco cessation journey. 

Absolutely, we know that a large proportion of those who quit will go back to smoking, especially in the first year after quitting and will benefit greatly from having a relapse prevention plan.  

Quitting smoking is a significant accomplishment, but it's important to recognise that the journey to becoming a non-smoker doesn't end with just quitting. Supporting the patient with relapse prevention strategies is a fundamental part of the support programme and vital to ensuring they remain a non-smoker for good. Many ex-smokers may face challenges or triggers that could potentially lead to a relapse. A relapse prevention plan is designed to help individuals identify these challenges and develop strategies to cope with them. 

Reducing prevalence in the general smoking population as well as among higher risk groups is a priority and measures can be taken locally and nationally to improve access to those often hard to reach groups of patients. Talking to your local authority public health prevention team can often be a good starting place as they will have the knowledge and experience of targeting these populations for other health and well-being areas. 

The offer of support should be made available to everyone with a tobacco dependency. The benefits are listed here - https://www.nhs.uk/better-health/quit-smoking/benefits-of-quitting-smoking/   

The benefits and risks to health can be explained to all patients in relation to their current health issues and then the decision can be made by the patient as to whether they would like support. No-one should be denied the opportunity to access tobacco dependency treatment. 

Helping people with dementia or learning disabilities requires a compassionate and tailored approach. Remember that every individual is unique, and the approach to tobacco dependency should be personalised, based on their needs and abilities. It's essential to work closely with healthcare professionals, including doctors and specialists in dementia or learning disabilities, to ensure the best possible care and support. It is important to collaborate with care support workers and family members to create a consistent and supportive approach. They can help reinforce the message and encourage the person to stick to their plan of stopping smoking.