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Secondary care and smoking services in Wales. Dr Keir E Lewis Reader in Respiratory Medicine & Consultant Chest Physician. Declaration of interests. Research grants: Pfizer (£135,000), Glaxo-Smith Kline (£9,000), Cardiff University (£2000)

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Secondary care and smoking services in wales

Secondary care and smoking services in Wales

Dr Keir E Lewis

Reader in Respiratory Medicine & Consultant Chest Physician


Declaration of interests
Declaration of interests

  • Research grants: Pfizer (£135,000), Glaxo-Smith Kline (£9,000), Cardiff University (£2000)

  • Conference attendance and honoraria for lectures and advisory boards: GSK, Pfizer

  • Smoking cessation specialist HDd HB: Pfizer (£5900)

  • (Honorary) Trustee for ASH Wales


  • It is the imperative of every lover of mankind, to unite in suitable

  • efforts to remove this rapidly increasing evil . . . and its enslaving power on the habits . . .and also, by seeking to deter others, especially the young, from acquiring this unnecessary, offensive and injurious practice.

  • 6th Principle British Anti-Tobacco Society, 1853.


Identifying the need political
Identifying the need - Political suitable

  • ‘ . . smoking is the greatest single cause of preventable illness and premature death in the UK . .’GovtWhite Paper 1988

  • NHS Smoke Free 2007

  • Wales Tobacco Action Plan 2012-

  • Presentation to Health Minister

  • Health Board’s Smoking Policy


Triggers for most recent quit attempt
Triggers for most recent quit attempt suitable

Data from 1237 smokers who tried to quit in past year, surveyed May 2009 onwards; smokers

could select more than one item

5




Not all smokers are created equal
Not all smokers are created equal! suitable

  • Hospitalised smokers often:

  • -Older

  • -More addicted (e.g. higher Fagerstrom scores)

  • -Are already unwell

  • -Have multiple illnesses

  • -Are on multiple drugs (potential for interactions)

Rigotti NA et al. ( 2007 ). Interventions for smoking cessation in hospitalised patients . CochraneDatabase of Systematic Reviews , 3 , CD001837


But hospitalised patients
but hospitalised patients… suitable

  • More open to help at a time of perceived vulnerability

  • Teachable moments

  • Place where smoking is restricted anyway

  • Pharmacological aids (should be) readily available

  • At least 33 well-designed trials

Cochrane Review updated 2008


Identifying the need patients
Identifying the need - Patients suitable

  • A secondary care service is VERY cost effective

  • £426 per LYG1

  • 26% adults in Hywel Dda smoke

  • 246 COPD admissions (current smokers 63% more likely > 3 adms/yr2)

  • < 10% smokers in chest clinic prefer a community service3

  • Surgical benefits (complications, repeat surgery, LOS 2 days longer)

  • Cardiac procedures etc . .

1JR Soc Health 1998; 118(6),

2. Garcia-Aymerich2003

3. Thorax 2005; 60 (ii): 37)


Where do patients prefer a stop smoking service to be located?

  • Inpatients:

  • 80 % of smokers attending MAU would like to receive some counselling during admission4

  • Outpatients:

  • 65% of smokers attending Chest Clinics would prefer their SSS to based wholly or partly in Secondary Care5

4. Murphy J, Williams A [Unpublished]

5. Thorax 2005; 60(s) ii37: S105


Nice technical appraisal no 38 7 3 2003
NICE Technical Appraisal No. 38, 7.3, 2003 located?

  • ‘‘ Arrangements should be made to ensure that smoking cessation advice and support is available to patients at both community and hospital locations. ’’

www.nice.org


Only 4 from 17 Welsh hospitals have a dedicated located?

smoking cessation specialist


Costs of a secondary care service
Costs of a secondary care service located?

  • Staff: 2 part-time specialists (Band 6) (£31,800)

  • NRT: (£12000) see later

  • Consumables: room, telephone, photocopying (£1000) (eCO monitors -free)

  • Publicity (£7000 WAG monies)

TOTAL: £45, 000


Publicity
Publicity: located?


Who refers to the hsss n 513 between 2007 2008
Who refers to the HSSS? located?(n=513 between 2007-2008)


Results 0 3 years
Results (0-3 years) located?

  • Patients: n=1033,SVQR 28%. Referral rate was increasing

  • Staff:

  • -84 attended, 32 sustained quitters (saving approx £32K)

  • Research / publicity /teaching:

  • -2 papers, 1 book, 12 abstracts, invited talks (worldwide!)

  • -medical student elective placement

  • -1 portfolio, 1 pharmaceutical study

  • - Core Competency in FP1 and FP2, ST training week


Risks of not meeting the secondary care need
Risks of located?not meeting the secondary care need

  • Patients: Breaking NICE Guidance, more ill health, more costs, despite highest level of medical evidence and local validation / business cases

  • Staff: more sickness, extra breaks, fire insurance

  • Teaching: none

  • Political: difficult to implement national and HB Policies


Http www brit thoracic org uk delivery of respiratory care stop smoking champions aspx
http://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspxhttp://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspx


Secondary care and community services joined up
Secondary care and community services – joined up??http://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspx

Hospital

More motivated to quit because of acute symptoms

Smoking is prohibited

Less triggers

Pharmacotherapy readily available

Medical support for drug interactions, illnesses

Community

Closer to home

Flexibility

No parking fees!

Less of an illness

Longer-term relationships


450 PATIENTShttp://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspx

randomised

150 PATIENTS

150 PATIENTS

150 PATIENTS

Counsellor

1 week

2 weeks

3 weeks

4 weeks

Counsellor

1 week

2 weeks

3 weeks

4 weeks

Advice / NRT

Tel no. / Leaflet

Phone / fax

DIRECT referral

Tel no. / Leaflet

Validated CO

-3 months

-6 months

-12 months

Validated CO

-3 months

-6 months

-12 months

Validated CO

-3 months

-6 months

-12 months


J Tob Nicotinehttp://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspxRes 2009; 11: 756-64


Joined up working
Joined up working?http://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspx

  • Hospitalised smokers don’t switch to a community service

  • Hospitals merely referring to a Community Service are not helping their patients

  • Having a Community Specialist doing 1-2 sessions per week is probably not enough


Only 4 from 17 Welsh hospitals have a dedicated http://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspx

smoking cessation specialist


Key challenges vision for the future
Key Challenges / Vision for the futurehttp://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspx

  • Increase provision in secondary care

  • Standardise service in secondary care

  • Standardise data sets in secondary care

  • Increase referrals to / awareness of SCS in secondary care

  • Research


Aged 33http://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspx

Bryan Curtis aged 34

from

St Petersburg Times 1999

(www.whyquit.com)


Summary
Summaryhttp://www.brit-thoracic.org.uk/Delivery-of-Respiratory-Care/Stop-Smoking-Champions.aspx

  • Smoking cessation within secondary care is needed

  • Smoking cessation within secondary care is clinically effective

  • and extremely cost-effective

  • Smoking cessation provision within secondary care in Wales is very low (<25%) and is the lowest the UK


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