Recent developments in smoking cessation policy

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

Smoking is estimated to be the leading cause of preventable illness and death in England, killing more than 82,000 people each year (almost 20% of deaths in adults aged 35 and over), and costs the NHS an estimated £2.7 billion per annum. In June 2009, the government announced that it plans to roll out nationally a new systems-based smoking prevention primary care policy. The policy has been piloted successfully at the local level, and this report will detail the specifics of the intervention.

Recent developments

The aim of the approach to smoking cessation is to encourage healthcare professionals to 'treat' smoking in a routine and systematic manner, in the same way that they currently treat, say, hypertension or high cholesterol levels. Therefore, the new policy is intended to encourage GPs to go beyond giving basic advice to smokers about quitting (as they have been encouraged to do up until now), and to incentivise GPs to actively manage smokers, in much the same way as they actively manage chronic illnesses. By doing so, GPs will be able to earn 'QOF points' (QOF is the performance management tool that determines a part of GPs overall earnings - therefore, by linking smoking cessation management to QOF, the provision of this service will enable GPs to increase their incomes, a mechanism that has been shown to be a powerful incentive with respect to other aspects of care that they provide).

Over the months following June 2009, trained 'NHS Stop Smoking Service' advisors were charged with helping those working in primary care to introduce this new approach to smoking cessation. The intention is to ensure that smokers who pass through primary care settings will routinely receive advice on how to stop smoking. This systems-based approach to smoking cessation will be 'tiered', where support will be offered at three different 'levels', from brief advice that lasts for 30 seconds to more intensive support, tailored according to how much time the patient and professional have. 

The approach will comprise of ten 'components', which are meant to work together to ensure that the whole healthcare team work together to help the patient quit smoking. Specifically, these components comprise:

• senior level commitment;
• incentives;
• protocol;
• teamwork;
• training;
• environment;
• resources;
• therapies;
• NHS stop smoking information;
• feedback. 

Particular emphasis has been placed on providing a supportive environment in primary care that demonstrates a commitment to help people to stop smoking.

Also in June 2009, the government announced that it is allocating £2.5 million to the 25 local authorities that have the highest numbers of smokers, so that each can develop programmes to help smokers quit (i.e. each participating local authority receives £100,000 for this purpose, which doesn't sound like an awful lot of money to me). Since this initiative is targetted at the local authorities with the highest numbers of smokers, it appears to be linked in some way to the government's broader strategy to reduce inequalities in health across England (also see report HPM 13/2009).  

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

The approach does seem reasonably innovative, but I don't think it is controversial, and public awareness of the initiative, unless you are a smoker who has recently been offered cessation advice under this policy direction is, I think, marginal. The approach will not fundamentally change the whole structure of healthcare delivery, and I wouldn't think that it would be difficult to transfer the initiative to other healthcare systems, if policy makers so desired.   

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Government

• Providers: Some Primary Care Trusts that pioneered the systems-based approach outlined above

• Scientific Community: Some academics whose expertise lies in the area of general practice

Stakeholder positions

The systems-based initiative has shown some success in local pilots (on which I provide some details below), and is essentially being rolled out as a 'top-down' measure from central government. I have not personally heard about any strong objections to this initiative, which, at face value, seems to be a pretty unobjectionable policy direction. The approach has also been supported by some academics working in the area of general practice, who are endeavouring to change the perception of smoking from that of an 'unfortunate behaviour' to that of a 'treatable condition' (much like, for example, hypertension), as discussed above.

Actors and positions

Government
Central government	very supportive		strongly opposed
Providers
Pioneer Primary care trusts	very supportive		strongly opposed
Scientific Community
General practice experts	very supportive		strongly opposed
current    previous

Influences in policy making and legislation

Not applicable

Legislative outcome

n/a

Actors and influence

Government
Central government	very strong		none
Providers
Pioneer Primary care trusts	very strong		none
Scientific Community
General practice experts	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

The approach is currently being implemented, and I would presume that those who are potentially most affected are primary care professionals and smokers. GPs can earn QOF points from implementing the service, although I suspect that their already substantial time constraints will affect the level of support that they will be able to offer in practice.

Monitoring and evaluation

An evaluation of the approach at the national level (England) will be undertaken in April 2010. As noted above, the approach has been piloted at the local level - in Yorkshire and Humber in the north of England, trained stop smoking advisors were offering advice between January 2007 and September 2008, during which time referrals to local NHS Stop Smoking Services increased by 49% across nine GP practices. This is perhaps encouraging when one notes that Ferguson et al. (2008) have observed that people referred to smoking treatment services are up to four times more likely to quit smoking than those who aren't.

Expected outcome

It is really too early to comment. What I can say is that the pilot project in Yorkshire and Humber seemed to show positive results, and if that type of performance can be replicated at the national level, then this approach may well prove to be highly beneficial. It would also demonstrate the worth of experimenting at the local level, as local innovation may offer good lessons for national policy directions, and thus local innovation ought to be encouraged in all policy domains.

A cautionary note could be struck, however, by pointing out that NHS (including of course PCT and GP) resources and time are already stretched, and it is not clear that significant efforts can be directed to smoking cessation advice without being detrimental to other (less targeted) aspects of health service delivery. Thus, it may be the case that the new smoking cessation initiatives will either not be fully implemented, or, if they are (and since they are linked to the QOF, they may well be), other aspects of care may suffer as a consequence. Only time will tell if this concern is legitimate.  

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

We do not yet know what impact the policy will have on quality, equity and efficiency. If the Yorkshire and Humber experience is replicated nationally, the initiative may well improve the quality of primary care services at the national level. If those most likely to quit smoking as a result of the initiative are from lower socio-economic groups (which is a very strong assumption), it may narrow socio-economic inequalities in health, and if the policy shows good effectiveness at low cost (in relation to which the level of the QOF payment incentives will play a strong part), then it may prove to be cost-efficient. But these are all big 'ifs'.

References

Sources of Information

Department of Health. New primary care approach boosts referrals to NHS stop smoking services by 49%. 2 June 2009. http://nds.coi.gov.uk/content/detail.aspx?NewsAreaId=2&ReleaseID=402513&SubjectId=2.

Department of Health. Councils awarded £2.5 million to stub out smoking . 10 June 2009. http://nds.coi.gov.uk/content/detail.aspx?NewsAreaId=2&ReleaseID=403121&SubjectId=2.

Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one-year outcomes. Addiction 2008; 100(Suppl. 2): 59-69.

Reform formerly reported in

Smoking ban in public places Process Stages: Implementation, Evaluation, Legislation, Change

Author/s and/or contributors to this survey

Adam Oliver

Suggested citation for this online article

Oliver, Adam. "Recent developments in smoking cessation policy". Health Policy Monitor, October 2009. Available at http://hpm.org/survey/uk/a14/1