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Why the UK is still lighting up

Graham Cope explains the looming threat to the provision of smoking cessation services

Smoking is the most important lifestyle factor ruinous to health, and cessation counselling with drugs is one of the most cost-effective interventions to reduce ill health and prolonging life. Yet news that the number of people using NHS smoking cessation services decreased by 11% last year, the sixth year in a row that the level has fallen, is worrying. Also, prescriptions for nicotine replacement therapies in England have decreased by 75% in the past decade due to a cut in funding for cessation treatments. These facts are stark indicators that programmes to help people stop smoking are in crisis.

Local councils were forced to adopt public health services in 2013, since when many local authorities have opted to disinvest in stop smoking services, which are not mandatory. A recent survey showed that 50% of local authorities in England cut their stop smoking budgets in 2017, 59% cut them in 2016, and 39% did so in 2015. Helen Walters, a public health consultant and member of the Faculty of Public Health’s Health Improvement Committee said: ‘Smokers who wanted to quit were more likely to succeed through NHS services than on their own…smokers need as much help as they can get’.

Overall investment in NHS stop smoking services around England has decreased by 14% in the past three years, from £70.2m in 2016-17 to £60.3m in 2018-19 and some councils have scrapped their services entirely. Sohail Bhatti, consultant in public health and deputy chair (local government) of the BMA’s Public Health Medicine Committee expressed concerns that cuts were disproportionately affecting vulnerable groups. He said: ‘In local government, everything has become politicised. The high profile things are protected, and unfortunately there aren’t voters crying out for a stop smoking service.’

BMA public health committee chair Dr Peter English said: ‘There is a need to reverse the cuts to public health budgets as in many areas, public health services do not adequately meet the health needs of the local population. Reductions to services such as smoking cessation and sexual health in some areas are directly contributing to unacceptable variations in the quality and quantity of care available to the population.’

Yet Westminster politicians appear to disregard these calls for change. In the foreword to Department of Health and Social Care (DHSC) policy paper Prevention is Better Than Cure, the DHSC secretary Matt Hancock described prevention as ‘crucial to improving the health of the whole population.’ Yet in a separate statement, he added: ‘We know that smoking contributes to 4% of all hospital admissions in England each year. And smoking costs the NHS around £2.5bn each year… The next step towards a zero-smoking society is highly targeted anti-smoking interventions, especially in hospitals.’

In response to this the Royal College of Surgeons recently issued a report advocating redistributing smoking cessation to secondary care. Although around 1 million smokers are admitted in England at least once a year, a recent audit found that smoking status was not ascertained in one in four admissions. Among those who admitted to be current smokers, less than a third were asked if they wanted help to quit, and only 8% were referred to stop smoking services.

So a major cause of their illness was effectively being ignored. The report advocated moving responsibility for smoking interventions back into the NHS in England, and to use commissioning processes, including a standard tariff for treating tobacco dependence, to ensure that treatment of smokers becomes a core NHS activity.

This may be a good idea but research of this approach in the US hospital care, stated there were significant barriers to this method to work efficiently, if at all. The most commonly identified barrier was lack of knowledge among clinicians, lack of time and a lack of perceived patient motivation to quit smoking. Other healthcare workers also reported a plethora of barriers to providing smoking cessation interventions in hospital settings. It is possible that these problems could be overcome by addressing the issue in a multidisciplinary approach, but unfortunately it appears the will is not there to implement it.

As a likely first point of contact for patients who smoke, GPs should play a crucial role in identifying smokers and signposting expert support. And the RCGP has guidance to help doctors feel confident in discussing smoking and this has recently been updated to include the very latest information on different types of quitting aids including e-cigarettes. Yet GP and primary care triggered quit attempts have fallen in recent years, but healthcare professional prompts are the second most common reason for someone to make a quit attempt. With smokers seeing their GP 35% more than non-smokers, there are frequent opportunities to offer interventions. But the strain on primary care, with increasing demand will have the knock-on effect of reducing the time given to helping smokers quit. Even though the Very Brief Advice model is designed to limit the consultation time to help make every contact count if the system is overwhelmed there is still not enough time.

One factor that has influenced the reduction in smoking cessation attempts and so the need to seek counselling is the use of electronic cigarettes. Since their introduction into the UK in 2007 the number of regular users is now over 5 million. But the medical and scientific opinion of these devices as far as being effective smoking cessation aids, their long term safety, and as ‘gateways’ to tobacco smoking in adolescents is divided, with many experts in the UK advocating their use, while in the US there is far more scepticism.

In an attempt to resolve these differences the UK Parliament under took an enquiry, taking verbal and written evidence over a three week period and subsequently produced a Green Paper. In the report the MPs called for a relaxation of regulations on e-cigarettes, that users of the devices should not be treated the same as conventional cigarette users (as they are 95% safer) and so they should be allowed to be used in public spaces including public transport. This, the report states will encourage more people to stop smoking and reduce the damage caused by tobacco.

Unfortunately the enquiry failed to acknowledge evidence pointing to the toxic nature of nicotine, particularly to pregnant women and those with respiratory disease and to the unknown effect of inhaling glycol and flavourings. Many people are replacing tobacco with e-cigarettes, but the long term effects of chronic use are not yet established. Perhaps users should be encouraged only to use these devices as a short-term measure to wean themselves off nicotine, otherwise the addiction for the substance will continue.

Finally, worrying news was announced recently that Sainsbury’s supermarket has signed the first deal in the UK to distribute the e-cigarette called JUUL. This is a phenomenon, not only because it claims to have 70pc of the US e-cigarette market, but it has been linked with widespread use by teenagers and adolescents. This is largely because it looks more like a UBS memory stick than a conventional e-cigarette and has one of the highest levels of nicotine in available devices.

The news left anti-vaping campaigners fuming. One said Sainsbury’s ‘should hang their heads in shame’. Another called it a ‘surprising’ decision, given recent commentary about JUUL by the US Centers for Disease Control and Prevention (CDC). In it Robert Redfield, MD, director of CDC, said ‘The popularity of JUUL among kids threatens our progress in reducing youth e-cigarette use…we are alarmed that these new high nicotine content e-cigarettes, marketed and sold in kid-friendly flavours, are so appealing to young people.’

The decline in the NHS smoking cessation counselling service will dramatically slow the decline in tobacco use. Responsibility to help smokers quit could and should be handed over to hospitals treating smoking related diseases but it appears the willingness to do so is not there. GPs have more contact with smokers, yet time pressures restrict their ability to engage with smokers, even at the minimal level. And the increasing use of e-cigarette has been supported by the UK MPs, and that could encourage another generation of addicts.

There is a still a lot of work for healthcare professionals and policy makers left to do to stub out smoking.

Graham Cope is a freelance medical writer