Performance of English stop smoking services in first 10 years: analysis of service monitoring data
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4921 (Published 20 August 2013) Cite this as: BMJ 2013;347:f4921
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
The analysis by West and colleagues of performance of NHS Stop Smoking Services (SSS) from 2001 through 2010 is troubling. No improvement in program rates in more than a decade (Table 1), "medications" being forced upon quitters at unprecedented rates (91% during 2010/11), a dismal one-year rate of only 15 percent after NHS poured more than £1 billion into cessation during the decade reviewed,[1] clearly, the primary beneficiary of NHS SSS has been the pharmaceutical industry.
Between 2000 and 2012, NHS spent £1.2 billion on smoking cessation (£647.8 million on services and £562.9 million on approved quitting products)[1] with, as I'll show, nearly zero return. Accepting the authors' data and calculations, by my calculation, NHS is spending £7,416 ($11,561) for each 1 year ex-smoker in excess of quitting over would have occurred anyway; what the authors term program "impact" quitters.
While no relevance beyond cost versus use, as director of WhyQuit, a leading abrupt nicotine cessation site (cold/smart turkey), during the past year we spent a total of $91.68 (our annual web-hosting charges) in attracting 2.3 million unique visitors who generated 34.8 million site requests. In contrast, NHS spent £153 million for smoking cessation, in serving 816,444 quit attempts,[1] 85 percent of which failed.
I submit that "medication" is undercutting successful SSS cessation. For a host of reasons, including blinding concerns so great that they forced resort to active placebos containing small amounts of nicotine for at least 15 years,[2] clinical NRT efficacy failed to transfer into real-world effectiveness.[3]
As evidenced by a July U.S. Gallup Poll, most successful ex-smokers are quitting cold turkey.[4] In fact, all approved quitting products combined account for only a tiny fraction of U.S. cessation (8%). Imagine nicotine gum, after 40 years and billions in marketing, only being credited for 1 in 100 successful ex-smokers. On this point, NHS would be wise to demand an independent UK population quitting method effectiveness assessment.
Why would NHS again spend £31 million on replacement nicotine, when year after year 4-week data show NRT users failing to prevail over those quitting without it? Keep in mind, that at 4 weeks, receptors in the brain of the SSS cold turkey quitter have already re-sensitized, down-regulated and fully adjusted to functioning without nicotine, while the NRT quitter has another 4 weeks of nicotine use before attempting to adjust to natural dopamine pathway stimulation. While it makes NHS declaring successful cessation at 4 weeks sadly comical, it may explain why the one-year rate in the 2005 Ferguson SSS study was only 15.2 percent for NRT quitters, while 25.5 for those quitting without it.[4]
If less than 10% of successful UK ex-smokers used approved products (as is the case here in the U.S.) what logic is there in using a fiction (100% use) in computing a make-believe control group in order to evaluate SSS performance? The authors acknowledge that the SSS 4 week cessation rate is actually not four weeks but instead a two week point prevalence rate ("service users were asked if they had smoked at all in the past two weeks" - see pg 2, Methods, paragraph 4).
That's important because the authors then make an apples to oranges comparison of the SSS point prevalence rate to a continuous cessation rate from the Hughes 2004 "relapse curve" study. To quote from the Hughes study, "Because our interest is in success on a given attempt, we examined prolonged abstinence with no grace period rather than point prevalence rates."[5] Also, although the authors suggest its use, I could not locate any four week data within the Hughes study.
Worthy of note, the Hughes study heaps praise upon the 1989 Cohen et al study, which examined and combined 10 unassisted control group studies involving more than 5,000 quitters (x3 the Hughes sample). While the Cohen study does not present 4 week rates either (a highly unusual cessation finish line), unlike the Hughes study, it does share a one-year unassisted point prevalence rate of 13.9%[7]
How meaningful is the SSS 15% one-year point prevalence rate if 13.9% would have succeeded on their own? I submit that NHS has absolutely nothing to lose and everything to gain by directing SSS counselors to study and give priority to sharing the art, science and psychology of successful abrupt nicotine cessation [8].
[1] HSCIC, NHS Stop Smoking Services Collection, http://www.hscic.gov.uk/stopsmoking
[2] Jarvis MJ, Raw M, Russell MA and Feyerabend C, Randomised controlled trial of nicotine chewing-gum, Br Med J (Clin Res Ed). 1982 August 21; 285(6341): 537–540 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1499070); Sønderskov J, Olsen J, Sabroe S, Meillier L, Overvad K, Nicotine patches in smoking cessation: a randomized trial among over-the-counter customers in Denmark, Am J Epidemiol. 1997 Feb 15;145(4):309-18 at page 312 (http://aje.oxfordjournals.org/content/145/4/309.long); and Campbell IA, Prescott RJ, Tjeder-Burton SM, Transdermal nicotine plus support in patients attending hospital with smoking-related diseases: a placebo-controlled study, Respir Med. 1996 Jan;90(1):47-51, at page 48 "Patients in the P [placebo] group received a transdermal formulation with a very low content of nicotine (13% of the active form), a dose which is conventionally felt to be too low to affect outcome." (http://www.ncbi.nlm.nih.gov/pubmed/8857326).
[3] Doran CM, Valenti L, Robinson M, Britt H, Mattick RP. Smoking status of Australian general practice patients and their attempts to quit. Addict Behav 2006;31:758-66 (http://www.ncbi.nlm.nih.gov/pubmed/16137834); Pierce JP, Cummins SE, White MM, Humphrey A, Messer K, Quitlines and Nicotine Replacement for Smoking Cessation: Do We Need to Change Policy?, Annu. Rev. Public Health 2012. 33:12.1–12.16 (http://www.ncbi.nlm.nih.gov/pubmed/22224888);
[4] Gallup. Most U.S. smokers want to quit, have tried multiple times. July 31, 2013. http://www.gallup.com/poll/163763/smokers-quit-tried-multiple-times.aspx
[5] Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one-year outcomes. Addiction2005;100(suppl 2):59-69. www.ncbi.nlm.nih.gov/pubmed/15755262
[6] Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction2004;99:29-38. http://www.ncbi.nlm.nih.gov/pubmed/14678060
[7] Cohen S, Lichtenstein E, Prochaska JO, Rossi JS, Gritz ER, Carr CR, Orleans CT, Schoenbach VJ, Biener L, Abrams D, Debunking myths about self-quitting. Evidence from 10 prospective studies of persons who attempt to quit smoking by themselves, Am Psychol. 1989 Nov;44(11):1355-65. http://www.ncbi.nlm.nih.gov/pubmed/2589730
[8] Spitzer, J Never Take Another Puff, 2002, free PDF book http://whyquit.com/joel/#book; Polito J, Freedom from Nicotine – The Journey Home, 2009, free PDF book http://whyquit.com/ffn/index.html; Carr, A, The Easy Way to Stop Smoking
Competing interests: Pro bono director of an abrupt nicotine cessation forum and author of Freedom from Nicotine - The Journey Home, a free PDF book which is also available through Amazon.
The most obvious explanation for the variation in quit rates between areas is that some services are more objective than others in assessing their own performance.
Unfortunately these services were never setup in a way which enabled evaluation of their effect on what matters which islong term abstinence.
My own gp experience is that long term abstinence is a result of motivation and family culture and not about the means of withdrawal and that very few or none of the long term quitters have attended a stop smoking service.
Surely smoking is a public health pproblem to be dealt with by public policy. Targeting a few individuals with methods which are well known to be ineffectual is a wasteful distraction.
Competing interests: No competing interests
West et al [1] report that across 10 years, 5,453,180 smokers attended and set quit dates at English smoking cessation services operating through 151 English Primary Health Care Trusts (PHCTs). However, they do not specify if these were unique individuals or included multiple attendances by some smokers.
By applying relapse estimates to their four week data, they calculate a 12 month cessation yield above that which would have been expected from just writing a prescription for a smoking cessation treatment. For the most recent year this was an additional 21,723 ex-smokers. Averaged across the 151 PHCTs, this is 144 per PHCT, less than 3 each week. England has some 11.22 million smokers aged 16 and over [2], and some 33.3% made a quit attempt in 2011[3]. So the maximum annual reduction in national smoking prevalence attributable to the PHCT centres might be about 0.19% (19 in 10,000 smokers) or 0.58% of all those in England making a quit attempt.
To get more perspective on this, it is likely that many of these cessation centre attending smokers would have stopped anyway in the absence of the centres because it has always been the case that most people who quit smoking do so independent of any formal assistance, pharmacological or behavioural. In 1975, before nicotine replacement therapy or today’s pharmacotherapies were available 32.6 million Americans were former smokers [4]. Some 30 years after NRT became available and benefitted from nearly three decades of heavy promotion, a 2013 US Gallup survey on methods used by ex-smokers reported only 8% used NRT or medication [5]. In England, 4.8% of people who smoked in 2010 were not smoking in 2011 [3]. This translates to some 538,560 ex-smokers. Those additional 21,723 who quit for 12 months after attending an English cessation PHCT centre thus represent about 4% of all those who most recently quit for 12 months.
From the variability in cessation across the PHCT centres, the authors argue that those which provided less intense support should be funded more to allow greater intensity of contact and higher quit rates to occur. If a goal of such services is to contribute meaningfully to population-wide cessation, West et al’s data would suggest that such centres are a very short tail on a much longer dog; unlikely ever to be a significant platform for reducing smoking prevalence under realistic funding increases; and exemplify the inverse impact law of smoking cessation [6]. West has described the cessation services as the “jewel in the crown of the NHS” [7]. If services responsible for 4% of quitters are described like this, what superlatives are appropriate descriptions for the policy and advocacy factors which motivated 96% of smokers who quit long-term without needing to access the services?
1. West R, May S, West M, Croghan E, McEwen A. Performance of English stop smoking services in first 10 years: analysis of service monitoring data. BMJ 2013;347:f4921
2. Health and Social Care Information Centre. Statistics on smoking – England, 2012 Aug 16, 2012. http://www.hscic.gov.uk/catalogue/PUB07019/smok-eng-2012-tab1.xls
3. West R, Brown J. Smoking and Smoking Cessation in England 2011. London. www.smokinginengland.info April 2012
4. Horn D. Who is quitting – and why. In: Schwartz J (ed) Progress in smoking cessation. Proceedings of an International Conference on Smoking Cessation. American Cancer Society: New York, 1978:p30.
5. Gallup. Most U.S. smokers want to quit, have tried multiple times. July 31, 2013 http://www.gallup.com/poll/163763/smokers-quit-tried-multiple-times.aspx
6. Chapman S. The inverse impact law of smoking cessation. Lancet 2009; 373(9665):701-3.
7. Tiggle N. NHS stop-smoking service 'a success' BBC News 20 Aug 2013
http://www.bbc.co.uk/news/health-23766070
Competing interests: Mike Daube is chairman of the Australian Council on Smoking and Health and Simon Chapman is on the board of Action on Smoking and Health Australia.
The report by West et al on the performance of the English stop smoking services (SSS) over the last 10 years shows an impressive three-fold increase in reach and impact(1). This is an important service and the financial support from local authorities should continue and increase in value.
My concern is the over reliance on the use of expired-air carbon monoxide (eCO) as a means to verify self-reported abstinence from tobacco. In the report the authors state ‘good practice required the stop smoking adviser to take an expired air carbon monoxide reading. If the reading was below 10 ppm, the four week quit status would be regarded as confirmed’.
The problem is that eCO is increasingly questioned as a reliable means of assessing abstinence from tobacco. Carbon monoxide intake is not specific to tobacco smoke, as it can be absorbed from environmental sources, such as traffic fumes and faulty domestic heaters, and false positive readings in SSS are not uncommon. The half-life of CO in the body is about 3 hours, meaning eCO only measures smoking habit for a 6-8 hour period, thus many smokers can abstain perhaps for a few hours and test negative. One recent study estimated that about 40% of those who smoked within 24 hours had CO reading below 10 ppm and the study’s results indicated a CO criterion of 5 ppm may be optimal to validate 24-hr cessation and reduce misclassification of smokers as “abstinent”(2).
While the use of eCO is useful as part of the SSS for participants to compare results and to provide feedback about their efforts to quit, more accurate and scientific methods should be employed to biochemically verify abstinence for official records, for example salivary cotinine, which can be carried out with inexpensive non-laboratory methods(3).
Perhaps, using eCO with a cut-off of 10ppm suits the SSS and those who support them, as this method will demonstrate a higher level of quitting than is actually the case. If the service wants to provide the most accurate assessment of the effect of the behavioural support provided by the service then they should use superior methods to assess smoking abstinence.
References
1. West R, May S, West M, Croghan E, McEwen A. Performance of English stop smoking services in first 10 years: analysis of service monitoring data. Br Med J 2013; 347: f4921.
2. Perkins KA, Karelitz JL, Jao NC. Optimal carbon monoxide criteria to confirm 24-hour smoking abstinence. Nic Tob Res 2013; 15: 978-982.
3. Cope GF, Wu HHT, O’Donovan GV, Milburn HJ. A new point of care cotinine test for saliva to identify and monitor smoking habit. Eur Respir J 2012; 40(2): 496-7.
Competing interests: GF Cope is the inventor of a point of care salivary cotinine test called SmokeScreen and he is a director of the manufacturer, GFC Diagnostics Ltd.
West et al have reported the great progress of the NHS smoking cessation schemes.
But there is more to be done. Between 1990 and 2011 the number of male smokers rolling their own cigarettes more than doubled (18% to 40%). [1] Female hand rollers rose 13 times over in the same period (2% to 26%). [1]
These hand rolled cigarettes are less likely to be smoked with a filter, and the tobacco content of each cigarette is estimated by the smoker.
Smokers are choosing cheaper and less regulated alternatives as prices increase. The most extreme of this spectrum is black market cigarettes (such as Jin Ling - a brand only produced for the black market, and readily found in the UK). [2] It is these products that need to be a central focus of the stop smoking efforts. It has the potential to undo all the great work being done, as a higher percentage of the reduced total number of smokers will become ill earlier.
1. ASH (2013) Who smokes and how much. Available from www.ash.org.uk/files/documents/ASH 106.pdf
2. Gross, Terry (21 July 2009). "Tobacco Fuels Addiction, And Terrorism". National Public Radio. Retrieved 24/8/2013
Competing interests: No competing interests
Stop smoking services: France must look over the English Chanel.
West and colleagues reported the brilliant work of the English stop smoking services from 2001/02 to 2010/11.(1) This is part of the comprehensive plan for tobacco control developed in the UK. In the 1998 White Paper ‘Smoking kills’ the Government set a target to reduce adult smoking rates from 28% to 21% or less by 2011. The latest national survey shows that this target has been achieved for the general population and that the number of ex-smokers now exceeds that of smokers.(2)
As many, I was not aware that the services are free to users.(1) Only a small prescription charge for medications is payable and people on low incomes, over 60 years of age, or pregnant/postpartum and patients with certain medical conditions are exempt.(1)
In contrast, in France, despite a mandatory health insurance scheme, smokers are only reimbursed 50€ for smoking cessation medications. In 2011, health minister Xavier Bertrand even banned varenicline from this ridiculous reimbursement and the number of persons treated felt from 283 000 in 2010 to 89 000 in 2012.(3)
In 2004, the French public health law set targets for smoking rates: from 33% to 25% for men and from 26% to 20% for women. In 2010 rates were 32% and 26%, respectively.(4)
1 West R, May S, West M, Croghan E, McEwen A. Performance of English stop smoking services in first 10 years: analysis of service monitoring data. BMJ. 2013;347:f4921.
2 Action on Smoking and Health. Smoking statistics. July 2013. Avalaible at ash.org.uk/files/documents/ASH_106.pdf.
3 Lermenier A. Tabagisme et arrêt du tabac en 2012. Observatoire français des drogues et des toxicomanies 2013. Avalaible at http://www.ofdt.fr/ofdt/fr/tt_12bil.pdf.
4 Direction de la recherche des études de l’évaluation et des statistiques. L'état de santé de la population en France - Suivi des objectifs annexés à la loi de santé publique. Rapport 2011. Avalaible at http://www.sante.gouv.fr/IMG/pdf/esp2011_14_tabagisme_obj3.pdf.
Competing interests: No competing interests
Re: Performance of English stop smoking services in first 10 years: analysis of service monitoring data
In Western countries, the prevalence of cigarette smoking has steadily decreased amongst all age groups. [1-3] As West et al demonstrate, relatively successful cessation programs have been implemented and nicotine replacement therapy is available over the counter at most pharmacies.[1] The anti-smoking campaign has been successful if one compares current smoking prevalence to that of the 50’s and 60’s, but what of the minority of current smokers who cannot or will not quit? Cigarette smoking is an addiction and addicts’ ability to quit varies. The rate of decline in smoking prevalence has slowed in recent decades and it is unlikely that smoking prevalence will decrease to zero. [1-3] Perhaps it is time to consider expanding current harm reduction strategies to include information that promotes screening and early presentation that will target inveterate smokers who cannot or will not quit.
Harm reduction in its broadest definition refers to “the introduction of policies and programs which aim to reduce the health, social, and economic costs of legal and illegal psychoactive drug use without necessarily reducing drug consumption”. [4] Current harm reduction efforts for smokers are restricted to strategies such as smokeless tobacco products for those individuals who are unable or unwilling to eliminate nicotine use (inveterate smokers). [5, 6] Inveterate smokers could benefit from the addition of further harm reduction strategies that could take the form of information provision about the importance of screening for smoking related cancers and acting promptly when symptoms appear. Such warnings could reduce the number of late smoking-related cancer diagnoses and result in earlier detection of other smoking-related health problems such as coronary vascular disease.
Since information provided on cigarette packages has been proven effective at communicating the cancer risks associated with smoking,[7,8] it makes sense to use this venue as a harm-reduction strategy to provide additional information. For example, the most common smoking-related cancer, lung cancer, is now a screenable disease. Evidence suggests that low-dose computed tomography has the potential to reduce mortality from lung cancer by as much as 20% amongst high risk current and previous heavy smokers. [9] Furthermore, some of the most common smoking-related cancers are that of the upper aerodigestive tract, particularly that of the throat and oral cavity. [8] The early signs and symptoms of throat and mouth cancer are easy to recognize,[10] but they are often ignored or attributed to benign causes due to patient’s lack of knowledge.[11,12] Information provided to participants in randomized trials tailored to inform people about the existence of screening tests and/or the early signs and symptoms of cancer has been found to be efficacious at communicating information and providing opportunities for early detection. [13-15]
In sum, it is likely that the smoking population in Western countries consists partly or largely of a core group who are unlikely to quit despite the use of graphic and shocking warnings that smoking can cause life threatening illnesses. A comprehensive harm reduction strategy that includes informing smokers of screening opportunities and encourages them to seek professional help promptly when they notice early warning signs could decrease the number of smokers diagnosed with late stage smoking related disease and greatly improve their chances of survival.
REFERENCES
1 Reid JL. Tobacco Use in Canada:Patterns and Trends, 2012 Edition. 2012.
2 CDC: Smoking. http://www.cdc.gov/nchs/fastats/smoking.htm 2013.
3 Cancer Research UK: Smoking. http://www.cancerresearchuk.org/cancer-info/cancerstats/types/lung/smoki... 2013.
4 The International Harm Reduction Association: What is Harm Reduction?: A position statement. 2010.
5 Zeller M, Hatsukami D. The Strategic Dialogue on Tobacco Harm Reduction: a vision and blueprint for action in the US. In: Tobacco Control. 324–32. 2009.
6 Phillips C V. Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments. Harm Reduction Journal;6. 2013
7 Hammond D. Health warning messages on tobacco products: a review. Tobacco Control;20:327–37. 2011.
8 Hammond D, Fong GT, Borland R, et al. Communicatng Risk to Smokers: The Impact of Health Warnings on Cigarette Packages. Am J Prev Med;32:202–9. 2007.
9 Manser R, Lethaby A, LB I, et al. Screening for lung cancer. Cochrane Database of Systematic Reviews 2013.
10 Canadian Dental Association: Oral Cancer. http://www.cda-adc.ca/en/oral_health/complications/diseases/oral_cancer.asp 2013.
11 Scott SE, Grunfeld EA, Auyeung V, et al. Barriers and triggers to seeking help for potentially malignant oral symptoms: Implications for interventions. Journal of Public Health Dentistry;69:January–2009.
12 Queenan JA, Gottlieb BH, Feldman-Stewart D, et al. Patient and family appraisals of symptoms of head and neck cancer. Queen’s Cancer Research Insttiute, Division of Cancer Care and Epidemiology.
13 Humphris GM, Ireland RS, Field EA. Immediate knowledge increase from an oral cancer information leaflet in patients attending a primary health care facility: a randomised controlled trial. Oral Oncology;37:99–102. 2001.
14 Humphris GM, Duncalf M, Holt D, et al. The experimental evaluation of an oral cancer information leaflet. Oral Oncology;35:November. 1999.
15 Humphris GM, Freeman R, Clarke HMM. Risk perception of oral cancer in smokers attending primary care: A randomised controlled trial. Oral Oncology;40:October. 2004.
Competing interests: No competing interests