Leading the Way: Smoking Cessation
Services in Health Action Zones
Catherine Adams, Linda Bauld and Ken Judge
University of Glasgow
Report submitted to the Department of Health,
November 2000
For more information please contact:
Linda Bauld: L.Bauld@socsci.gla.ac.uk
Catherine Adams: catherine.adams@ntlworld.com
CONTENTS
Page No.
INTRODUCTION
Smoking and Deprivation
Health Action Zones and Deprivation
Aims and Methods
3
MAPPING ALL 26 HAZs
Service Structure and Interventions
8
8
10
11
11
12
12
14
15
16
16
19
Specialist Services
Intermediate Services
Target Groups
Staffing
NRT
NRT budget
Impact of one week’s free
Monitoring
Smokers setting quit dates
Evaluating monitoring results
CASE STUDIES
The Case Study HAZs
Case Study Interviews
Staffing
Service Structure
Specialist and Intermediate Services
One-to-one and group support
The interface with primary care
The NRT voucher system
Reaching target groups
Monitoring
Delivering services and collecting data
Monitoring design
Smoking reduction
Monitoring results in the case studies
5
5
6
21
21
29
29
30
30
31
32
33
35
37
37
38
39
39
Next Steps
42
44
References
45
CONCLUSION
2
INTRODUCTION
It is now widely accepted that the UK is in the grip of a tobacco epidemic (Godfrey et al,
1993). There are currently about 13 million adults who smoke – approximately 27 per cent of
the British population. Smokers in the UK also smoke more cigarettes than the European
average. The consequences of smoking are many. It is the single largest cause of preventable
illness and premature death. Smoking accounts for a fifth of all deaths in the UK, and it has
been estimated that one in two long-term smokers will die as a result of smoking (Peto et al,
1994) and half of those will die before age 69. Patterns of morbidity are also closely related to
smoking. Smokers face a higher risk than non-smokers of dying from many diseases, as Peto
and colleagues have outlined (1992):
! A twenty-fold higher risk from lung cancer
! A tenfold risk from chronic obstructive airways disease
! A 1.5 to threefold risk from coronary heart disease.
In addition to the health risks to the individual that are attributable to smoking, there is a
considerable cost to the health service. It is estimated that, in England, 284,000 patients are
admitted to NHS hospitals every year as a result of disease related to smoking. These patients
occupy an average of 9,500 hospital beds every day. Smoking also results in over 7 million
prescriptions each year (Godfrey et al, 1993). Smoking is estimated to cost the NHS up to
£1.7 billion annually (Department of Health, 1998).
In response to the overwhelming evidence of the harmful effects of smoking, the government
published a White paper on tobacco, Smoking Kills, in December 1998. The white paper set
out a “£100 Million war on tobacco”, which aimed to reduce the number of people smoking
by 1.5 million by 2010 (Department of Health, 1998b). This involves a strategy to tackle
smoking which includes measures to clamp down on tobacco advertising, address cigarette
smuggling, promote clean air initiatives and invest in health education and media campaigns
to reduce smoking. At the core of the white paper are a range of measures to help people stop
smoking, particularly disadvantaged adults, young people and pregnant women.
New smoking cessation services were set up as a result of recommendations in the White
paper, with specific funding of up to £60 million to be made available to health authorities
over three years to establish these new services. In the first year following the publication of
Smoking Kills, funds were provided only to Health Action Zones. HAZs were established in
1998 in 26 areas of England as trailblazers to modernise the NHS and to tackle health
inequalities (Judge and Bauld, 2001). HAZs were targeted in year one as part of the
government’s strategy to reach disadvantaged smokers. £10 million was made available to
the Zones for twelve months from April 1999.
Smoking prevalence in communities within Health Action Zones is amongst the highest in
England. The only available representative source of information regarding prevalence rates
by Health Authority is the Health Survey for England. Although prevalence data for
individual health authorities from the Health Survey for England (based on aggregations of
the years 1994-96) are subject to wide confidence intervals they are the best available figures
for smoking prevalence at health authority level and as such provide a useful snapshot of the
problem of smoking across HAZs. Table 1 presents prevalence rates by each health authority
in Health Action Zones.
3
Table 1.
Smoking prevalence for cigarette smoking across Health Authorities
(1994-1996)
Standardised Standardised
Rate per 100 Rate per 100
MALES
Sub health authority HAZs
Luton
29.7
Plymouth
33.7
Leicester
31.9
Brent
30.8
Single health authority HAZs
Bradford
28.6
E London and City
35.5 -high
LSL
38.9 -high
N Cumbria
26.7
Northumberland
30.9
Hull and East Riding
35.2
Bury and Rochdale
35.5
Camden and Islington
36.2
Leeds
25.7
Cornwall
30.8
N Staffs
32.6
Nottingham
26.4
Sheffield
23.8 -low
Tees
30.9
Wakefield
28.1
Walsall
40.9 - high
Wolverhampton
26.4
Sandwell
36.3
Multiple HA HAZs
MST
- Manchester
32.4
- Salford & Trafford
26.1
SYT
- Barnsley
28.2
- Doncaster
42.6 -high
- Rotherham
33.8
Merseyside
- Liverpool
29.6
- St Helens & Knowsley
30.3
- Sefton
33.2
- Wirral
25.3
Tyne and Wear
- Gateshead & South Tyneside 35.9
- Newcastle & North Tyneside 25.4
- Sunderland
33.5
All England
29.8
Standardised
Rate per 100
FEMALES
ALL
24.4
31.9 -high
22.5 -low
25.0
27.1
32.8 -high
27.1
27.7
30.5
27.4
33.3 -high
28.9
28.3
29.6
37.3 -high
27.9
26.0
31.3
28.4
27.4
29.0
33.8
34.4
30.9
30.3
33.2
29.6
31.1
35.9 -high
27.5
29.4
32.0
36.6 -high
31.6
25.8
31.1
30.2
26.9
26.7
32.5
31.6
35.8 -high
28.5
34.5
43.8 -high
32.2
38.5 -high
29.3
22.5
31.4
32.6
25.1
36.5
33.3
37.7 -high
32.9
30.7
28.9
34.1 -high
31.5
32.1
27.0
33.0 -high
31.3
36.1
34.2 -high
28.5
35.0
27.8
28.8
Bedfordshire HA
SW Devon HA
Leicestershire HA
Brent and Harrow HA
Notes: 1: "High"/"Low" values identify HAs whose standardised estimates are significantly higher/lower than average for England at
the 95% confidence level
2: Source - Department of Health - Health Survey for England 1994-96
Produced by Social and Community Planning Research (SCPR), March 1999
As Table 1 illustrates, over two-thirds of health authorities within Health Action Zones have
smoking prevalence rates higher than the national average for men and women, which in
4
these figures (which relate to 1994-1996) stood at just under 29 per cent. Just two health
authorities within HAZs (Leicester for females and Sheffield for males) have smoking rates
that are statistically significantly lower than the national average. (In Leicester the figure is
lower for females only, in Sheffield it is lower for males). In contrast a number of health
authorities within Health Action Zones have overall prevalence rates that are 20 per cent or
more above the national average overall rate of 28.8 per cent (i.e. in excess of 33.5 per cent).
The reasons for this relate to the level of deprivation present in communities within Health
Action Zones, and the relationship between deprivation and smoking.
Smoking and Deprivation
There is now a sizeable body of research evidence that examines the relationship between a
range of socio-economic factors and smoking prevalence. The basic facts are that people in
manual socio-economic groups, with lower incomes who live in areas of social deprivation,
are far more likely to smoke. This pattern of observed prevalence is at least partially a product
of the fact that cigarette consumption has been declining in Britain overall for more than two
decades, but at the same time there has been a significant widening of the gulf in smoking
between social groups (Jarvis, 1997). Very recent published evidence from the 1998 Health
Education Monitoring Survey in England summarises the patterns (ONS, 2000):
•
•
•
•
When measures of social class are employed, those classified in social class I/II were
least likely to be current smokers – 21 per cent of men and 20 per cent of women,
compared with at least 31 per cent of men and women in other social classes.
When household income is examined, smoking prevalence decreases as gross
household income increases. The highest smoking prevalence is amongst men and
women with a gross household income of under £5,000 (48 per cent of men and 32 per
cent of women).
Employing measures of economic activity, the highest proportions of current smokers
are amongst the unemployed.
When measures of deprivation are used, smoking prevalence increases with area
deprivation. Individuals living in deprived areas are most likely to be smokers, with
one third of women in the two most deprived area types being current smokers,
compared with one-quarter or fewer of women in more affluent areas.
Similar evidence of the links between socio-economic circumstances and smoking prevalence
can be found in the 1998 General Household Survey. For example: “Men who lived in
households in the unskilled manual group were nearly three times as likely as those who lived
in professional households to smoke; 44 per cent did so, compared to 15 per cent.” (ONS,
2000, page 119).
Health Action Zones and Deprivation
Over 13 million people live in areas within Health Action Zones. Many of these individuals
live in fairly affluent circumstances, but a greater proportion experience poverty on a day to
day basis. The high smoking prevalence rates identified in Table 1 within HAZs are related to
these patterns of deprivation. The DETR, in conjunction with researchers at the University of
Oxford, has recently developed a new index of local deprivation (see http://www.detr.gov.uk).
5
This new index is more comprehensive than its predecessors in that it contains a wider range
of indicators across a number of domains, including health. Analysis of this new index
demonstrates the extent to which HAZ areas represent the most deprived communities in
England:
•
•
•
81 of the most 100 deprived wards in England are located within Health Action Zones
Half of all HAZ wards are in the most deprived quintile of wards in England as a
whole
Less that 20 per cent of all HAZ wards are in the 50 per cent least deprived wards in
the country.
By providing the year one Smoking Kills money for cessation services to Health Action
Zones, the government has demonstrated its commitment to targeting services on those
communities where the need is greatest. However, new services take time to plan and
implement. Developing the new services has been challenging and at times difficult. This
report outlines the process of development in year one.
Aims and Methods
The year one evaluation of smoking cessation services began in September 1999. The study
aimed to explore strategic issues relating to the development of the new services. The
Department of Health has established a monitoring system for the new services, which
involves health authorities submitting quarterly and annual returns reporting on the number of
smokers setting quit dates, staffing and budgetary details. However, analysis of routine
monitoring data cannot address issues of service development, and thus the research team
conducting the National Evaluation of Health Action Zones were approached to conduct an
additional piece of work that focussed specifically on smoking cessation.
The research was intended to be primarily descriptive, and aimed to provide insights that
could inform the wider implementation of the Smoking Kills reforms in years two and three.
The brief agreed by the Department of Health and the evaluation team involved research at
two levels. Level one would involve base-line data collection and analysis across all 26
Health Action Zones. This constituted a broad mapping exercise that was to be informed by
smoking cessation action plans, quarterly monitoring returns and commentaries, annual
reports and initial interviews with smoking cessation co-ordinators across all Health Action
Zones.
Level two of the monitoring exercise consisted of a more detailed investigation of smoking
cessation in selected HAZs. This involved documentary review and in-depth interviews in a
sample of seven Zones, in order to obtain more comprehensive information relating to the use
of new monies and the development of services. Fieldwork for this part of the evaluation was
conducted near the end of the first year of services and into the beginning of year two. Thus a
number of issues which relate to policy developments in year two are raised in the report,
primarily because they will have a considerable impact on the future development of services
across the country.
The report draws on information from the main sources of our research:
• semi-structured interviews with smoking cessation co-ordinators in all HAZs, conducted
between November 1999 and January 2000;
6
•
•
•
semi-structured interviews with key smoking cessation staff in seven case study HAZs
conducted in June/July 2000.
quarterly monitoring returns submitted by HAZs to the Department of Health (DH) for all
four quarters of year 1 (from 1 April 1999 - 31 March 2000);
written plans and commentaries which accompanied those monitoring returns, as well as
annual commentaries which were supplied by HAZs.
Interviews were conducted in all 26 Health Action Zones between early November 1999 and
mid January 2000 with smoking cessation coordinators or their equivalent. Findings from
these interviews were presented in an interim report submitted to the Department of Health in
February 2000, entitled Smoking Cessation: Early Experiences in Health Action Zones. An
executive summary of this report is available on the HAZ website, HAZNet
(http://www.haznet.co.uk/hazs/evidence/smoking-exec-sum./pdf). Selected findings from the report were
also published in the Health Services Journal in July 2000 (Adams et al, 2000). This first
round of interviews was followed up in June/July 2000 with more in-depth interviews in
seven case study areas. These case studies sites were selected in consultation with colleagues
at the Department of Health, using a range of criteria including location, size, health/local
authority configuration and progress in developing the new services by the first half of year
one.
The case study interviews were carried out with a range of key individuals involved with
smoking cessation. The researchers identified categories of individuals who were deemed
important to interview, in order to better understand the development of the new services
from a range of perspectives. This list of categories was sent to each smoking cessation coordinator who then provided contact details for suitable informants in their HAZ.
Interviewees thus included smoking cessation coordinators, managers in the health authority,
smoking cessation specialists, intermediate advisors, pharmacists, health promotion managers,
PCG representatives, and GPs. A total of forty one people were interviewed across the seven
HAZs. Interviews with co-ordinators and some senior managers were tape-recorded and
transcribed in full. Responses to questions in the remainder of the interviews were recorded
on paper by the interviewer and summarised in a word file immediately following each
interview. Material from the transcripts and the interview summaries was then analysed
thematically, by two members of the research team. The findings from these interviews are
presented in the Case Study section of this report.
Throughout our one year study, we have been receiving the quarterly monitoring returns
submitted by HAZs to the Department of Health. The DH is conducting its own detailed
analysis of this material and as a result we have used monitoring data primarily as contextual
material to support findings from the interviews and documentary review. Upon receiving the
returns each quarter, we entered all the monitoring data onto Excel spreadsheets. Findings
from the monitoring returns presented in this report relate to the original figures that we
received. Since these were submitted, some modification has taken places for a small number
of Health Action Zones. The Department of Health is analysing the year one returns in more
detail, and final figures will shortly be available in a statistical bulletin. Provisional figures
were released in August 2000. (Department of Health. August 2000).
A final set of data for our work were the quarterly and annual commentaries submitted by the
HAZs. These documents accompanied the monitoring returns and provided additional details
about developing service structure, staffing and NRT arrangements. The level of detail
contained in these returns varied considerably between HAZs. However, these documents
7
were reviewed and an Access database was set up to facilitate comparison of their contents
across the 26 Zones.
The remainder of this report consists of two main sections:
!
!
Mapping all 26 HAZs; which builds on material in our interim report produced in
February 2000. It provides an update on the progress made by all Health Action Zones in
developing smoking cessation services during 1999/2000.
The Case Study HAZs; which provides more detail about the development of smoking
cessation services during 1999/2000 based on fieldwork in a sample of seven Health
Action Zones.
MAPPING ALL 26 HAZS
Our February 2000 interim report presented early findings from the implementation of
smoking cessation services in HAZs. Developing and beginning to establish the new services
was an extremely challenging exercise for those involved in smoking cessation across all 26
Zones. In most areas, services were slow to develop and a number of problems were
encountered. It is worth summarising some of the barriers to progress that we identified in
that report. These included:
!
!
!
!
!
!
Lack of clarity about the structure of services and the distinction between intermediate
and specialist interventions;
A range of problems concerned with setting up the voucher system and supplying NRT to
eligible smokers;
Issues around availability of adequate training for advisers;
Establishing monitoring systems;
Involving PCGs and other agencies in planning and delivering services; and
Recruiting and retaining staff.
Health Action Zones have made considerable progress in developing their services since the
interim report was written. This first section of our final report provides an update on progress
across all 26 Zones in relation to four themes of particular importance:
!
!
!
!
Service structure and interventions
Staffing
NRT
Monitoring
Each of these themes, as well as a range of other issues, are also dealt with in more detail in
the Case Study component of our report, which provides a more in-depth description of
service development in seven HAZs.
Service Structure and Interventions
Following the publication of Smoking Kills, HAZs were issued with guidance (HSC
1999/087) outlining an appropriate structure for the new services. These recommendations
8
were based on the available evidence base, particularly the 'Thorax' supplement, Smoking
Cessation Guidelines and their cost effectiveness (Raw et al, 1998). This called for a service
based on a range of interventions - from opportunistic interventions by health care
professionals through to specialist clinics, group work and one-to-one counselling.
The guidance identified three different levels:
- Brief or ‘opportunistic’ smoking cessation interventions that are provided by a variety
of health professionals in their day to day contact with clients/patients
- Intermediate interventions that aim to provide support on a 'one-to-one basis by
practitioners who have undertaken some form of accredited/recognised training'.
- A dedicated specialist smoking cessation service delivering more intensive
interventions that generally involves group support provided by trained specialist
advisers over a period of five to six weeks, and NRT.
The money made available to HAZs following the publication of the white paper was
intended to fund the development of services at the second and third level – so called
‘intermediate’ services and specialist services. As our interim report outlined, there was some
initial confusion regarding what constituted an intermediate service and precisely what the
distinction between specialist and intermediate was in practice. However, despite this lack of
clarity the new services aimed to provide support to smokers at both levels.
The speed with which different HAZs had both levels of service in operation varied
significantly in year one. Some had both levels of service established and running by the
second quarter, whereas others had chosen to concentrate their efforts on just one level. Some
chose to begin running intermediate services first, while others introduced the specialist
service first. Several HAZs, such as Nottingham, Northumberland and Sheffield, initially ran
services in pilot form in selected areas in order to test their approach.
In most cases, HAZs chose to formally launch their service. This involved investing in
publicity and attempting to inform professionals and the general public about what was being
provided. Figure 1 shows the launch dates. This updates the previous graph in the interim
report that showed projected dates for some HAZs.
9
Launch Dates for Specialist Service
26-Mar-00
25-Feb-00
26-Jan-00
27-Dec-99
27-Nov-99
28-Oct-99
28-Sep-99
29-Aug-99
30-Jul-99
30-Jun-99
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As Figure 1 shows, Lambeth, Lewisham and Southwark were the first to launch their
specialist service on 1st June 1999, whereas Leeds, Northumberland and Wakefield did not
formally launch their services until March 2000.
The overall configuration of services varies between HAZs. In order to provide a more
detailed picture of the types of services that HAZs were providing at the end of year one at the
brief, intermediate and specialist levels, Box 1 sets out a few examples.
10
Box 1. Examples of smoking cessation services at brief, intermediate and specialist levels
Level 1 – Brief
Level 2 - Intermediate
Level 3 - Specialist
Bradford
Pilot scheme in Airedale area school nursing service offering
smoking cessation
support to secondary school
children.
Manchester, Salford and
Trafford
Trafford North PCG funding a
community project. This is
being implemented by
Trafford’s substance misuse
Service and will involve
recruiting 10 New Deal workers
to train as Intermediate
Advisors
Cornwall
Smoking cessation
counselling for heavily
addicted smokers. This
involves addiction
counsellors in main
surgeries who take referrals
from GPs for patients with
multiple problems.
East London and City
Since January 2000 seven
intermediate advisors from
Bangladeshi and Turkish
communities trained to provide
smoking cessation advice.
They are currently offering
advice to 100 clients a month.
Training will be provided in the
future to Somali, Chinese
/Vietnamese to provide a
similar service to these
communities.
Plymouth
Specialist group run by
smoking
cessation
specialist
for
a
local
business which requested
the group as part of the
implementation of it’s No
Smoking Policy.
North Staffs
Sheffield
Specialist services run in a
wide variety of venues
including GP practices,
hotels, community centres,
voluntary organisations,
sports centres and clinics
Services are targeted at the
most deprived areas of the
city.
Brief advice in Healthy Living
Centres, Libraries, Pharmacies,
Mosque attached day centres
and other religious settings
Cornwall
Health visitor and midwives
trained in 4 'a's and delivered
special leaflets about quitting for
pregnant women and other
smokers in their household.
These midwives/health visitors
then refer smokers wishing to
quit to the intermediate service
or to the specialist pregnancy
service. The overall aim is to try
to ensure more babies born into
smoke-free households.
Manchester,
Salford
and
Trafford
Smoking is an increased risk
factor for cervical cancer and
therefore women attending for
colposcopy in hospitals in
Salford and Trafford are being
given smoking cessation advice
Smoking cessation and health
promotion
project
worker
working
with
community
development workers to recruit
local people to attend training
weekend (Jan 2000). Training
will
provide
community
members with the skills to run
quit smoking groups in their
local areas.
Specialist Services
The configuration of specialist services varied between HAZs. Some were running group
sessions from one main location. Others were running a largely peripatetic service with a
number of clinics /group sessions across a range of locations. The structure of specialist
services was determined by a range of factors, including: the size and nature of the
communities being serviced (in HAZs with rural areas, for instance, a peripatetic service was
essential); the pattern of pre-existing smoking cessation services in the area; and the approach
taken to target disadvantaged smokers, either through providing services in easily accessible
locations in deprived wards, or training local people from deprived areas to act as advisers.
There are a number of examples of innovative elements of service structure at the specialist
level. For example, Cornwall has employed addiction counsellors in some of the main
practices to take referrals from GPs for heavily addicted smokers with multiple problems. In
Sheffield, specialist services are being run in a wide variety of venues including more unusual
11
settings such as hotels, community centres, voluntary organisations and sports centres in an
attempt to make them more accessible.
Intermediate services
The development of intermediate services has to a large extent involved the training of health
care professionals to deliver one-to-one counselling usually in primary or secondary care
settings. Those most commonly cited as carrying out intermediate interventions include
practice nurses, midwives, health visitors and pharmacists. To a lesser extent other health
professional such as GPs, and hospital staff have been trained. In some HAZs, smokers who
have recently quit have been trained to offer services in their local community. Training local
people as intermediate advisers has also taken place in an attempt to reach particular groups.
In East London and City, for example, ex-smokers from ethnic minority communities have
received training as advisers in an attempt to overcome some of the cultural and linguistic
barriers which may discourage smokers from these communities from using the service.
One group of HAZs focussed on developing intermediate services in year one before
launching their specialist service. This group includes Walsall, Tees, Northumberland and
Plymouth. The most common reason for focussing effort at the intermediate level was due to
pre-existing smoking services in the area, or represented an attempt to get some services in
place quickly, as there were delays in implementing one or more elements of a specialist
model. For example, Tees had a trained nominated smoking cessation lead in all but one GP
practice in the Tees area. In addition they had trained a large number of staff in secondary
care including ward nurses, therapist, and midwives. Their specialist service has been slower
to develop. Similarly in Northumberland intermediate services were developed at a faster rate
than specialist services. This was largely due to the model of service developed, which was
peripatetic (because of the geography of Northumberland), and in an attempt to adequately
cover all parts of the county focussed on training professionals as intermediate advisers in a
range of NHS settings.
Target groups
Services at all levels are aiming to reach the target groups set out in the White Paper – namely
adults living in deprived communities, pregnant women and young people. We discuss the
issue of reaching these groups in more detail in the case study component of this report.
However, it is worth highlighting some material from the quarterly commentaries submitted
by HAZs that illustrates the profile of service users in year one.
A number of HAZs have reported that the majority of smokers using the new services are
female. In some HAZs, the ratio of women to men using services is as high as 2:1. It is not
clear why this is the case, although it may relate to the fact that services that use self-referral
as the primary form of access (this is true for services in most HAZs) will attract more female
smokers. This may be consistent with research suggesting that women are in some cases more
likely to seek support from formal services than men, although the evidence in this area is
mixed (Blaxter, 1990, Macintyre et al, 1996). These findings are also reflected in quit rates.
Provisional figures from the Department of Health for year one showed that a total of 14,585
persons had set a quit date of whom 5441 (37%) were male and 9,144 (63%) were female. In
relation to the age profile of service users, a local evaluation of the new services in
12
Merseyside found that the average profile of smokers using the service, and those most likely
to be successful in quitting were those in their forties and fifties (Lake, 1999).
In relation to low-income smokers, the evidence in HAZs’ own commentaries is scarce but it
was evident from our early interviews with all 26 co-ordinators (and subsequent interviews in
the case study sites) that good progress was being made in some HAZs in reaching these
smokers. Co-ordinators pointed to the high proportion of smokers who were eligible for free
NRT as one indicator of success. Others indicated that their policy of locating services in
community settings within deprived wards, or of training local people as advisers meant they
were reaching these smokers. However, the evidence at this stage is merely anecdotal and we
will need to wait until the next stage of the national evaluation (which will specifically
examine effectiveness of reach) to determine to what extent the new services are tackling
smoking in deprived communities. In relation to young people, evidence from the
commentaries is again limited but suggests that little progress was made in year one in
reaching young smokers. Younger smokers are particularly difficult to reach with traditional
interventions, and there is as yet limited research evidence about effective ways to encourage
smoking cessation in this group (Townsend, 1995, Raw et al, 1998). Very few HAZs had
information about particular services for young people in their year one plans, although most
stated their intention to develop these in year two. Amongst those HAZs that have made early
attempts to develop programmes for young people, however, success seems to have been
limited in year one. For example, a school-based scheme in North Staffordshire where pupils
were trained to offer peer support to smokers was poorly attended.
In addition, there has so far been limited success in attracting pregnant smokers, and smokers
from ethnic minorities in many HAZs, although some have had more success that others in
this area. Evidence from the case study HAZs regarding early experiences of attempting to
reach these groups is presented in the case study section of this report.
Staffing
As we highlighted in our interim report, recruiting suitably qualified staff for the specialist
service has been a problem for many of the HAZs. Recruitment or retention problems have
affected the quality of the services in year one. Sheffield HAZ was unable to fill the post of
smoking cessation coordinator until May 2000 despite numerous recruitment and advertising
campaigns. Other HAZs made early efforts at recruitment and then abandoned them in favour
of secondment arrangements. A further group of HAZs experienced major delays before
appointments could be made - some HAZs had to advertise up to three times. In Wakefield,
for example, the coordinator did not take up post until the final quarter of the first year, which
will inevitably have had an impact upon the development of services.
Overall the timing of smoking cessation co-ordinator appointments therefore ranged from
June 1999 to March 2000. Other posts for specialist and administrative staff were usually
filled after the coordinator came into post as he/she was usually required to have an input into
the recruitment process, and this meant further delay before staff took up posts and received
suitable training.
13
NRT
Smoking Kills stressed the importance of Nicotine Replacement Therapy as part of the new
smoking cessation services, emphasising the firm research evidence that NRT can be
instrumental in helping people to quit (Raw et al, 1998). From April 1999, one week free
NRT was made available to smokers using the new services who were eligible for free
prescriptions. Our interim report highlighted the difficulties some HAZs had in putting in
place arrangements for the distribution of one week’s free NRT. Negotiating the supply of
NRT and setting up the voucher system for its distribution was complicated, necessitating the
arrangement of contracts between health authorities and pharmaceutical committees, and also
the training of pharmacists.
In addition, co-ordinators and others working in smoking cessation were from the outset
extremely critical of the provision of only one week’s free NRT to those eligible for free
prescriptions, arguing that it would have only limited impact on quit rates, and that a longer
period of free NRT was necessary. Since then there have been a number of policy changes at
national level relating to the provision of NRT.
In July 2000, (DH 28/7/00) a letter was sent to all smoking cessation coordinators and leads in
response to proposals in the NHS National Plan, outlining the government’s commitment to
making NRT available on prescription. At the time of writing, a final date for this has not yet
been agreed, but it is unlikely to be before the next financial year (April 2001).
However, in October 2000, the DH agreed that in the intervening period, free NRT for those
eligible could be extended from one week to 4-6 weeks across all health authorities. It was not
compulsory for health authorities to comply with this, but the majority have taken this
opportunity to do so.
In addition, the Department of Health has now introduced a national NRT voucher scheme.
This is intended to replace local arrangements established by HAZs in year one. Not
surprisingly, professionals working in HAZs have not universally welcomed this new
development, for a number of reasons. Firstly, the majority of HAZs took a considerable
amount of time to develop their local voucher scheme. They are reluctant to make further
changes now that their schemes are up and running. In addition, some HAZs and health
authorities have resisted the national scheme on the basis that NRT will be soon be available
on prescription, meaning any vouchers may shortly become obsolete. This may now be
delaying the provision of NRT in some non-HAZ health authorities, as they are waiting for
NRT to become available on prescription.
Thus although there have been improvements in the provision of NRT, problems still exist,
and there is still some confusion and inconsistency about eligibility, voucher schemes and
length of time for provision. There is also clearly inequity in that some health authorities and
HAZs are providing free NRT for up to 12 weeks in some areas, whereas in other part of the
country smokers have variable access to free NRT at the present time.
Plans to introduce free NRT may also have been influenced by the arrival of the GlaxoWellcome product, Zyban. This is a sustained release preparation of the drug buproprion. In
June 2000, Zyban became available on NHS prescription (Secretary of State announcement,
26th June 2000). Zyban has demonstrated effectiveness in helping smokers to quit, although
14
the two main research studies published to date examined the use of the product in
conjunction with intensive support.
With this evidence in mind, The Department of Health has been keen to emphasise that both
the provision of NRT and Zyban should be backed up by motivational support and
counselling such as those provided by the new smoking cessation services. There is evidence
that the effectiveness of NRT is far greater if it is combined with a strong support network
and group or one to one support. The new services will therefore have a crucial role to play in
supporting the use of both Zyban and NRT. Experience in HAZs during year one reflect the
wider research evidence. Sheffield HAZ, for example, carried out local monitoring of the
provision of free NRT for one week, 6 weeks and 12 weeks. It was found that 6 weeks and 12
weeks were most effective at securing higher quit rates, but extended provision was even
more successful when used in addition to group support from smoking cessation services. In a
guidance letter on Zyban, (DH, 28 June 2000) intermediate services in primary care provided
by practice nurses were seen as a good location for the prescribing of Zyban backed up by
counselling and support.
As the service continues to develop it seems likely that provision of NRT and Zyban will
become more firmly established within the structure of new smoking cessation services. At
the time of writing, in November 2000, they were already an integral part of most services,
but the first year has seen a number of difficulties and inconsistencies in the way NRT has
been provided. The introduction of Zyban on prescription, and 4-6 weeks NRT free, followed
later next year by NRT on prescription should begin to address some of these problems, and
lead to greater equity in the provision of services across all HAZs and health authorities.
NRT budget
Our analysis of the monitoring returns for year one shows that by the end of quarter 4, the
majority of HAZs had underspent their NRT budget by a considerable amount. This is a
product of delays in setting up the arrangements for the distribution of free NRT. The
majority of HAZs took at least six months to set up the voucher scheme, negotiate distribution
arrangements with pharmacists and train advisers in their use.
The graph below shows the percentage of year 1 budget allocation spent by HAZs by Quarter
4. These figure should be interpreted with some caution as they represent original submissions
to the DH, with final validation still underway.
15
Figure 2. Percentage of Yr1 NRT budget spent by end of Q4
Percentage of Yr 1 NRT budget allocation
actually spent by end Q4
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Note: Final figures were not yet available for Merseyside, so their budget details are not included in the figure
As Figure 2 illustrates, 15 of the 26 HAZs had spent less than 20% of their allocated NRT
budget in year one. Plymouth, Wakefield and Sheffield were exceptions in that the amount
spent on NRT was close to their actual budget allocation. Tees was the only HAZ to
overspend its NRT budget. This occurred for a number of reasons. Tees along with many
other HAZs found it difficult to judge how much investment in NRT would be required in
year 1 before services were established. In addition, specialist services in Tees were not
launched until relatively late - the beginning of February 2000. However, following the
launch there was a rapid and sizeable uptake of services, with the vast majority of smokers
accessing the services eligible for free prescriptions, which quickly depleted the NRT budget.
Impact of one week’s free vs. additional weeks
Our analysis of quarterly commentaries and the interviews we have conducted has revealed
that a number of HAZs chose to fund additional week’s free NRT from their own budget, or
the budget of the Health Authority. In most instances, this was achieved because the policy of
one week free was perceived as inadequate by those involved in planning or delivering local
services, and considerable effort was exerted to identify funds to extend the national scheme.
As part of the ongoing work of the national evaluation of HAZs, we asked HAZ project
managers about the development of the new smoking cessation services in their area. One
HAZ project manager explained their local arrangements to extend the national NRT scheme:
We already had local investment in smoking cessation services, but when the new money
came to the Health Action Zone, [the smoking cessation co-ordinator] and I had
conversations about how we could enhance what was going into the existing service to make
it more available to particular target groups. I put some additional HAZ funding in so that we
weren’t limited to just one week of free NRT, so that it could be available to those who needed
it most for just a bit longer.
16
Additional information about local extensions of one week free was provided in the
commentaries submitted by co-ordinators. Due to the limited information provided in some
commentaries, we cannot comprehensively catalogue which HAZs extended the national
scheme in year one. However, we are able to give some examples, outlined in Box 2.
Box 2.
Walsall
Nottingham
Sheffield
Hull and East Riding
Merseyside
Tees
Plymouth
2 weeks followed by an extra 2 weeks at 50% subsidy.
This applies to all smokers accessing the service, not
just those eligible for free NRT
4 out of 6 PCG areas are providing 4 weeks free NRT
to eligible smokers
An evaluation has been carried out in services
providing free NRT for differing periods of time – for
1 week, 6 weeks, and 12 weeks. Quit rates have been
compared across these groups. Initial results showed
better rates for 6 and 12 weeks and more compliance
with NRT when attending specialist groups for
support.
Money from main HAZ project used to extend NRT
provision to 4 weeks free
In one small area of Merseyside, up to 12 weeks NRT
is funded by an Single Regeneration Budget scheme.
4 weeks free NRT being funded out of main HAZ
budget in 3 areas of Tees HAZ
Specialist group members are all given one weeks’
free NRT even if not entitled to free prescriptions. This
is funded by the District Smoking Prevention Alliance
who also agreed to fund three weeks free NRT to 2
groups which began March 2000, and also 8 weeks
free NRT in a low income area of Plymouth.
Additional weeks of subsidised or free NRT may have been available in other HAZs during
year one, either in specific local areas or across the HAZ. However, as this additional
provision was arranged outwith the central government funding for new services, the
commentaries submitted by smoking cessation co-ordinators did not always describe these
arrangements. That said a number of HAZs that were unable to extend one week’s free made
a point of emphasising this in their commentaries. In Cornwall and the Isles of Scilly, for
instance, free NRT was limited to the one week national scheme in year one, with advisers
instead recommending that smokers unable to pay for additional weeks NRT should take
dextrose, an alternative treatment supported by research evidence (West, 1999).
Monitoring
The Department of Health requires all HAZs and Health Authorities to submit quarterly
monitoring returns (for HAs this began in 2000/2001) that shows the number of smokers
setting a quit date during that quarter, the number who have successfully quit at four week
follow-up based on self-report, and whether this was confirmed by CO monitor reading. In the
interim report we presented figures for quarters 1 and 2, for this report we focus primarily on
figures for quarter 3 and 4.
17
Smokers setting quit dates
In August 2000 the Department of Health (DH. August 2000) published a statistical press
release that outlined interim findings from year one of the new services. Key findings from
the bulletin are summarised in Box 3.
Box 3.
STATISTICS ON SMOKING CESSATION SERVICES IN HEALTH ACTION
ZONES: ENGLAND, APRIL 1999 TO MARCH 2000.
This statistical press release presents provisional results from the monitoring of
the new smoking cessation services set up in Health Action Zones in England
during 1999/2000.
The results show that:
Around 14,600 people set a quit date through the smoking cessation services.
63% of those setting a quit date were females and 37% were males.
40% of those setting a quit date used specialist cessation services and 60% used
intermediate services.
79% of those setting a quit date were aged 18-59 years, 1% were aged under 18
and 21% were aged 60 or over.
At the 4 week follow-up 39% of those setting a quit date had successfully quit
(based on self-report); the success rate was higher for specialist services (48%)
than for intermediate services (34%).
Around 10,800 of those setting a quit date were entitled to free prescriptions and
so were eligible to receive free Nicotine Replacement Therapy (NRT)/NRT
vouchers.
Around 9,300 of people setting a quit date received free NRT/NRT vouchers,
64% of all those setting a quit date.
Produced by the Department of Health Statistics Division
The table below shows which HAZs had smokers setting quit dates for specialist services and
intermediate services in the third quarter (October – December 1999) and fourth quarter
(January-March 2000) of year one.
18
Table 2 Monitoring returns for third and fourth quarters
HAZ
Quit date information
provided third quarter
monitoring return
Quit date information
provided in fourth quarter
monitoring return
East London and City
Intermediate and specialist services
Intermediate and specialist services
LSL
Brent
Intermediate and specialist services
Intermediate and specialist services
Intermediate and specialist services
Intermediate and specialist services
Camden and Islington
Luton
Intermediate and specialist services
Intermediate and specialist services
Intermediate and specialist services
Intermediate and specialist services
Manchester, Salford
and Trafford
Hull and East Riding
Intermediate and specialist services
Intermediate and specialist services
Intermediate and specialist services
Intermediate and specialist services
Bury and Rochdale
Intermediate and specialist services
Intermediate and specialist services
South Yorkshire Coalfields
Intermediate and specialist services
Intermediate and specialist services
Cornwall and
Scilly
North Staffs
Intermediate and specialist services
Intermediate and specialist services
Intermediate and specialist services
Intermediate and specialist services
North Cumbria
Specialist services only
Intermediate and specialist services
Merseyside
Specialist services only
Intermediate and specialist services
Leeds
Specialist services only
Intermediate and specialist services
Nottingham
Specialist services only
Intermediate and specialist services
Tyne and Wear
Specialist services only
Intermediate and specialist services
Northumberland
Intermediate services only
Intermediate and specialist services
Plymouth
Intermediate services only
Intermediate and specialist services
Tees
Intermediate services only
Intermediate and specialist services
Wolverhampton
Specialist services only
Specialist services only
Leicester
Specialist services only
Specialist services only
Bradford
Specialist services only
Specialist service only
Sheffield
Specialist services only
Specialist services only
Walsall
Intermediate services only
Intermediate services only
Wakefield
Nil return
Intermediate and specialist services
Sandwell
Nil return
Specialist services only
Isles
of
Eleven HAZs had smokers setting quit dates for both specialist and intermediate services for
both the third and fourth quarters. As would be expected the majority of these were in HAZs
that launched their services early (in quarters one and two), and had smoking cessation staff in
post from an earlier stage, although there were a few exceptions to this pattern. All the
London HAZs had smokers setting quit dates for both quarters 3 and 4, reflecting the speed
with which services were able to be set up in London due to the existence of pre-White Paper
services in some areas, and the pool of staff able to be appointed early in the life of the new
services.
Five HAZs (North Cumbria, Merseyside, Leeds, Nottingham and Tyne and Wear) had
smokers setting quit dates for only specialist services in quarter 3, but by quarter 4 also had
19
quit dates for intermediate services. This showed that these HAZs had chosen to focus their
initial efforts on building a specialist service, for whatever reason, before introducing an
intermediate service. These tended to be HAZs that had taken longer to build a foundation for
services, perhaps running services in pilot form initially, such as Nottingham. It may have
also been that there were some delays in implementing intermediate services due to problems
negotiating access with PCGs and/or pharmacists. Merseyside attributed delays in setting up
the intermediate service to the tight timescale given to establish services. This was
compounded by the difficulty of coordinating and aggregating quarterly returns from 4 health
authority sites. However, Liverpool and Wirral had some intermediate services by the fourth
quarter.
Three HAZs, (Tees, Plymouth and Northumberland) had smokers setting quit dates for
intermediate services in quarter 3, but by quarter 4 had quit dates for both specialist and
intermediate. This may have been due to the pattern of services prior to the new smoking
cessation services or may be due to early planning to provide support to smokers in as many
settings as possible. In Plymouth intermediate advisors were trained at an early stage, and the
service was based in more than 50 settings. Other factors which may have also delayed the
setting up of a specialist service include delays in finding suitably qualified staff.
A further group of 4 HAZs (Wolverhampton, Sheffield, and Bradford and Leicester) had
smokers setting quit dates in the specialist service only. This was either due to delays in
setting up intermediate services or because of the way services were structured in these
HAZs.
Walsall had smokers setting a quit date at the intermediate level only in year one. We provide
more detail about Walsall’s service structure in the next section.
Sandwell and Wakefield submitted a nil return for quarter 3, but by quarter 4 Sandwell had
smokers setting quit dates for specialist services, and Wakefield had smokers setting quit
dates for both. Sandwell had services in place from an early stage, but had difficulty
completing their monitoring forms, as there were problems with their database. Wakefield’s
coordinator did not come into post until March 2000, which probably explains some of the
delay.
Evaluating monitoring results
As previously explained delays in setting up the new services, employing and training staff,
and establishing the NRT voucher scheme, meant smokers did not begin using the service in
many areas until the autumn of 1999, and in some cases not until early 2000. This led to a
sizeable proportion of nil returns for the first and second quarters as reported in our interim
report. There has been a significant increase in the number of smokers accessing the services
in quarters three and four.
20
Figure3
N um ber of p eople in H A Zs setting qu it dates during Q 3 by
10 0,000 pop ulation
200
180
160
140
120
100
80
60
40
20
Plymouth
Camden & Islington
E London & City
Cornwall
Brent
Merseyside
Luton
Walsall
Northumberland
Hull & East Riding
MST
Wolverhampton
Bury &Rochdale
Bradford
Sheffield
Tyne & Wear
S Yorkshire Coalfields
North Staffs
North Cumbria
LSL
Nottingham
Tees
Leicester City
Leeds
Wakefield
Sandwell
0
Sandwell were not able to supply full monitoring data to DH but did have had clients setting a quit date in the period
April to December 1999; around 100 clients set a quit date in Sandwell in Quarter 3.
Figure 3 illustrates the number of smokers setting a quit date in Quarter 3. It presents data by
100,000 population, allowing direct comparisons between HAZs. Numbers setting quit dates
during this three month period were comparatively small, with two HAZs (Sandwell and
Wakefield) submitting a nil return. Sandwell did have some people setting quit dates for this
quarter, but it was unable to submit a full return because of ongoing problems with its data
management systems. The low numbers setting quit dates for some of the other HAZs reflects
the fact that many of these did not fully launch their services until late into quarter 3 or even
quarter 4. However, these figures do represent a substantial improvement since the second
quarter, when eleven out of twenty six HAZs submitted a nil return. It is also worth noting
that several HAZs were already showing early success in achieving relatively high numbers
setting quit rates. (For example, Cornwall, East London and City, Camden and Islington, and
Plymouth). On the whole these were HAZs who launched their new services earlier in the first
year.
21
Figure 4.
Number of people in HAZs setting quit dates during Q4 by
100,000 population
250
200
150
100
50
Plymouth
MST
Tees
Tyne and Wear
Camden & Islington
Cornwall
E London & City
Merseyside
North Cumbria
Walsall
Sandwell
Wolverhampton
Northumberland
Brent
Wakefield
S Yorkshire Coalfields
Bury & Rochdale
LSL
Nottingham
Luton
North Staffs
Leicester City
Sheffield
Hull & East Riding
Leeds
Bradford
0
Figure 4 indicates illustrates the number of smokers setting quit dates in the last three months
of year one, from January to March 2000. Plymouth was particularly successful in reaching
smokers and encouraging them to set a quit date. Its success is particularly interesting as
Plymouth’s services were primarily based around intermediate provision until the end of year
one, with more limited specialist services. Plymouth was one of the first HAZs to launch its
services and has invested considerable effort in establishing cessation support across the
HAZ, facilitated by a co-ordinator who was appointed early in year one and who has
developed positive relationships with PCGs and other local partners. The other HAZs that
demonstrated early success in reaching smokers were Manchester, Salford and Trafford, Tees,
Tyne and Wear and Cornwall. It is also worth noting that two of the central London HAZs –
Camden and Islington and East London and City – where services were again established
early in year one – have demonstrated considerable success in reaching smokers relative to
other parts of the country.
What these figures do demonstrate – when compared with those for the interim report – is that
services are expanding rapidly, problems with database management systems are being
resolved, and that increasing numbers of smokers are now accessing the services and setting
quit dates.
CASE STUDIES
In the second half of year one, the research team conducted more detailed field work in a
sample of seven Health Action Zones. This section of the report outlines findings from this
work. Data collection consisted of reviewing in detail the monitoring returns and
accompanying commentaries submitted to the DH by each HAZ, and conducting a series of
diagonal slice interviews with key informants in each of the Zones. We divide our analysis
into three parts:
22
!
!
!
Pen portraits of each HAZ, which outline the structure of services and identify key issues
in service development up to May 2000.
Findings from interviews with a range of informants in each of the seven HAZs
Analysis of findings from the monitoring returns, which allow a comparison of overall
progress in year one in reaching smokers and encouraging them to quit.
Camden and Islington
Camden and Islington smoking cessation service is based in the Community Health Trust,
where the smoking cessation co-ordinator and administrator have their offices. The service is
operating at both the specialist and intermediate levels, as well as supporting practitioners
providing brief interventions. The specialist clinic operates at the Crowndale Health Centre.
The clinic director is Martin Jarvis, Professor of Psychology at University College London.
The clinic has a manager funded by a grant from the Imperial Cancer research fund, and two
specialist advisers provided by the Health Action Zone. While some HAZs have adopted a
peripatetic model for the specialist service, this as not been necessary in Camden and
Islington. The Crowndale clinic is relatively easily accessible by public transport, and
smokers can self-refer (in fact, almost all smokers attending the clinic are self-referrals).
In addition to the specialist clinic, group support for smoking cessation is also offered in one
general practice. The group receives a small amount of HAZ funding, but there are as yet
insufficient returns to assess the effectiveness of this group.
Intermediate services are operated by trained Smoking Cessation Advisors. There are three
full-time advisers, located in each of the three hospitals within the HAZ. Camden and
Islington also have a number of part-time advisers. These include community workers, health
visitors, practice nurses, health advocates, dentists and a few GPs. In particular, there are four
dedicated health visitors each working on a ½ day per week basis, one in each of the four
PCGs, and 3 midwives, again on a ½ day per week basis covering one in each hospital. The
intermediate advisers as a group are reporting very varied levels of contact with smokers,
usually due to the limited time they have available to act as advisers, but in some cases other
factors play a role. Problems between the hospital and the community trust have been
encountered, particularly in relation to the midwives and health visitors acting as advisors. As
a result, very few pregnant women had used the service as of June 2000.
An important component of the Camden and Islington service is support for members of
ethnic minority groups living in the area, particularly members of the Turkish, Kurdish and
Bangladeshi communities. Publicity has been targeted at these groups and the support
available involves one to one sessions with an intermediate adviser and access to NRT via the
voucher system. This part of the service has a high take-up rate, with the advisers seeing
about 20 smokers per half day session.
23
Leeds
Leeds Stop Smoking Service has been fully operational since March of 2000, and is
functioning at both the intermediate and specialist level. The co-ordinator and administrative
assistant manage the service from offices in a student medical practice which they have
moved into in May 2000. The process of setting up and implementing services in Leeds has
been challenging, particularly as the hospital Trusts in the area have recently reorganised. The
service is adapting to fit these new structures, and aiming to provide a service in line with the
five PCG areas in the city.
The specialist service is provided by four full-time and one part-time adviser, who accept
referrals from the administrative assistant who co-ordinates the contact telephone line. The
advisors are all professionally qualified staff, with a nursing qualification or similar. They are
working on a peripatetic basis across the city, with one in each PCG area. As of May 2000,
seventeen specialist clinics had been set up in a range of locations including medical and
health centres, a cancer information centre and some workplaces Initially the advisers were
providing only one-to-one support, but from May 2000 the intention has been to develop
group sessions as well. In addition to delivering services, the specialist staff also provide
training and support to intermediate advisors.
The intermediate service is provided by a large group of part-time advisers. The aim is to
eventually have 150 advisors in a variety of settings who are able to offer smoking cessation
advice. As of May 2000, there were 60 advisers from a range of professional backgrounds
who had received training and were and able to accept referrals. These advisers are providing
one-to-one support in clinics set up in a range of settings. The number of smokers seen by the
advisers varies significantly however. Some are seeing very few smokers, despite the advisors
themselves saying that they felt skilled and that they had the right support. One contributing
factor to low take-up may be the referral process, within the primary care setting particularly.
For this reason, specific funding is to be made available to each PCG to allow practice nurses
to devote a half-day session per week to provide smoking cessation services.
Some intermediate advisers are also operating in a hospital setting. These professionals have
either been recruited because they are already working in secondary care, or have been
employed specifically to conduct smoking cessation work. Supporting both specialist and
intermediate interventions is the NRT voucher scheme, which has been in operation since the
spring of 2000. Leeds is providing the standard one weeks free NRT.
24
Luton
In year one of the new services, Luton has developed a specialist model of smoking cessation,
but up until June 2000 did not have any significant intermediate provision. The service has
been developed and provided entirely by one part-time smoking cessation co-ordinator and
one part-time specialist adviser, along with some limited administrative support. The service
currently has its offices in the same premises as the Luton PCG.
The specialist service has been in existence since June 1999 and is provided on a peripatetic
basis. Finding suitable locations across the town has been a challenge, but the service is now
being provided in a number of venues including the Town Hall, a youth centre, a health centre
and some workplaces. It is run on the Maudsley model, and thus provides group support to
smokers who attend. One to one interventions have been offered, but take up has been slow.
As of May 2000, no formal intermediate service was operating, although one trained advisor
(a practice nurse) was seeing some clients. Development of the intermediate service is a
priority for year two. At the end of May, a training session was held for 20 future advisors
including a midwife, a respiratory nurse, practice nurses, community nurses, a couple of
health promotion specialists, a pharmacist and others.
Luton is offering the standard one week’s free NRT and a voucher system is now in place and
being used by the specialist service. However, only about 20 per cent of smokers attending
the clinics are eligible for free prescriptions. This suggests that the service is not yet reaching
the most disadvantaged smokers. The lack of intermediate service also means that other target
groups, particularly pregnant women and ethnic minorities, have not yet used the service in
any numbers, but efforts are being made in year two to reach these smokers.
Links with the one PCG that covers the HAZ area are not very well developed, despite the
fact that the service shares office accommodation with this PCG. Luton HAZ sits within the
larger Bedfordshire Health Authority however, and other PCGs in the wider area are now
linking with the service. Two of these PCGs have enquired about help with training. Indeed,
at the end of year one it was apparent that the Luton service is now acting as a model for the
development of year two services across the Health Authority area. The co-ordinator and
specialist adviser have been closely involved in planning and developing the expanded
service.
25
Merseyside
Merseyside Health Action Zone contains four health authorities; Liverpool, St. Helen’s and
Knowsley, Sefton, and Wirral. Each authority has established a smoking cessation service.
The four services are linked in a number of ways, and each contains common elements. One
of the four smoking cessation co-ordinators (in St. Helen’s and Knowsley) has been
responsible for collating plans, commentaries and monitoring returns across the four districts
since services were established in 1999. In addition, a Merseyside-wide smoking cessation
steering group acts as a co-ordinating body, with the overall service being known as
‘SUPPORT’. Common elements across SUPPORT include: Merseyside-wide training
sessions for advisers; a HAZ-wide publicity campaign; a single NRT voucher system; a
commissioned evaluation of year one across the four districts; and a common ‘gatekeeper’ to
all four services through the Roy Castle FagEnds service (although referrals can also come
from health professionals). Fagends is a long-standing Merseyside telephone quit line.
Smokers who contact this free phone service are provided with support and advice and
referred on to one of the four district cessation services if required.
Service across the four districts were officially launched in September 1999, but this launch
attracted little public attention. As a result, the service was relaunched in January of this year
and since then all four districts have seen a significant rise in the number of smokers using the
service.
Overall, Merseyside has adopted a specialist model of smoking cessation in an attempt to
follow the Thorax and Department of Health guidelines as closely as possible. At the end of
year one, intermediate services were only beginning to be developed. All four districts are
operating a peripatetic specialist service, in that trained advisers provide one-to-one support
and some group support in a range of settings in the community. Each district has a coordinator with administrative support, and a number of specialist advisers ( at the end of year
one, there were eleven trained advisers working in St. Helen’s and Knowsley, five advisors in
Sefton, six in Liverpool and four in Wirral; most of these advisers were working on a parttime basis). All four districts have made links with the hospital trusts in the area, for instance
in Liverpool one hospital-based midwife is currently acting as a specialist adviser on a parttime basis. In Sefton, St. Helens and Knowsley and Wirral however, problems with recruiting
and/or retaining advisers were prevalent in year one. An NRT voucher system was operating
well across Merseyside by January 2000. In addition, one area within St. Helen’s and
Knowsley has a pre-existing scheme of 12 weeks subsidised NRT, funded through Single
Regeneration Budget (SRB) monies until the end of 2000.
All four services have been involved in providing training to health professionals in brief
interventions, but as of May 2000, the absence of an intermediate tier has meant that direct
involvement by GPs or practice-based staff in the service has not been developed.
Relationships between the services and PCGs have been mixed across the four districts.
26
North Cumbria
North Cumbria’s smoking cessation service has been developed as a specialist service,
operating on a peripatetic basis. One to one and some group support is provided by a group of
ten smoking cessation advisers, all of whom have received training and all of whom live and
work in one of the HAZ’s priority areas. The service was developed in this way in order to
meet the needs of North Cumbria’s dispersed population, particularly smokers living in
isolated areas. Training local people to provide the service is an explicit attempt to address
government targets to reach smokers in deprived communities. The ten advisers are
community based, work part-time, and provide services in a range of settings (workplace,
community centre, GP practices and in people’s homes). In addition to these communitybased staff, the specialist service also advisers working in secondary care. Two of these
provide a service to in-patients and run a clinic for out-patients based on the Maudsley model.
The remaining two are midwives who work part-time as advisers. Although they are based in
a hospital setting, they also visit pregnant women at home.
North Cumbria is currently not operating an intermediate service. There have been attempts to
recruit and train practice nurses but only one (as of June 2000) is providing any smoking
cessation support and returning monitoring forms. Pharmacists are interested in becoming
intermediate advisers and one has undergone training but as yet none are operating as
advisers. The absence of an intermediate service and the nature of the specialist service mean
that there is no primary care involvement in the direct provision of smoking services in North
Cumbria. No GPs are currently involved in the new service, although one GP was involved in
developing the NRT voucher system.
Overall management rests with the smoking cessation co-ordinator, whose offices moved
earlier this year to the building in which the HAZ project manager and other HAZ staff are
located. This has allowed for greater integration with other HAZ programmes and some
sharing of administrative resources. The service also has a multi-disciplinary steering group
made up of representatives from the Health Authority, the three PCGs in the area, a
pharmacist (who is chair of the Local Pharmaceutical Committee) and others. No GPs sit on
the steering group, although the Director of Primary Care for the Health Authority is a
member.
The smoking cessation co-ordinator in North Cumbria acknowledged that services had been
slow to develop in the HAZ. Although the service began to receive referrals in December
1999, it was not fully functioning (including the NRT voucher system) until April 2000. A
range of factors can be identified to explain this slow development. Much of the explanation
lies in the fact that the co-ordinator herself was not appointed until July 1999, and so
recruitment of advisers, training etc. did not start until after that date. Setting up the NRT
voucher system has also been particularly difficult and protracted. However, from the Spring
of 2000, the service was successfully recruiting smokers across the HAZ and demonstrating
good quit rates at four weeks.
27
Nottingham
The Nottingham smoking cessation service is called ‘New Leaf,’ and was formally launched
in January 2000, following an initial pilot period. The smoking cessation co-ordinator is based
in the Health Authority, but the specialist advisers are located within a Voluntary Action
Centre. This location was selected following a period of public consultation which suggested
that a hospital-based service would not be as popular as one based in the community.
New Leaf is operating at both the specialist and intermediate levels. There are three full-time
specialist advisers who provide support to smokers from their base in the Voluntary Action
Centre. This support mainly takes the form of groups, but one to one sessions are also offered.
Several groups have been run in various locations throughout Nottingham.
At the intermediate level, a number of intermediate or locality advisors (about 35) have now
been trained. They are working in a range of settings, from primary care, to pharmacies, and
some in secondary care. These individuals are mainly health professionals, including health
visitors, hospital nurses, pharmacists and practice nurses. They tend to be seconded to work
about four hours per week on smoking cessation. Like the specialist service, the intermediate
service has a particular focus on providing support to smokers living in deprived wards of the
city. Areas in which the service has encountered difficulty in reaching smokers has been in
the case of pregnant women, and members of Nottingham’s ethnic minority communities,
very few of whom have used the service in year one.
Links with the local PCGs are well-developed, although GPs overall have been reluctant to
get involved in the new service, and none have been trained as intermediate advisers.
However, PCG support is evident in that four out of six PCGs have agreed to fund a further
three weeks NRT for eligible smokers. The other two seem unlikely to do so at the end of
year one which created problems of inequity for the PCG populations not entitled to the extra
NRT. It is hoped that this might change as PCGs move towards Trust status and services are
delivered differently.
28
Walsall
Walsall’s smoking service was launched in October 1999 and since then has been providing
services at the intermediate level. A specialist service was not operating in year one of
funding, although preparations were being made for a staged launch, which began in
September 2000. Both levels of service are managed by the smoking cessation co-ordinator
who is based within Walsall Health Authority. There is a tradition of fairly innovative
smoking cessation work in Walsall which the new services have tried to build upon. Since
1995, the Health Authority has been funding a programme of subsidised NRT, available
through GP’s practices. When the Smoking Kills funding became available through the HAZ,
the scheme was expanded from one-quarter of GP practices in the area to over half by June
2000. Currently, participating practices are able to provide all smokers with two weeks free
NRT, followed by an additional two weeks NRT at half price.
The intermediate service exists in all four PCGs, with a greater number of service providers in
those areas with the highest prevalence of smoking. At the level of the individual practice, not
all GPs are involved. For this reason there was some concern that GPs who were not involved
would be reluctant to refer their patients to another practice that was involved in the scheme,
for fear of losing patients. To address this concern, pharmacists who were already involved in
the NRT voucher exchange were recruited and trained to become intermediate advisors. As of
May 2000, there were three of these trained pharmacists. They are paid for their sessional
time in running half-day smoking advice clinics from their premises. The pharmacists’
involvement has thus far proved to be very successful and the eventual aim is to have two
trained pharmacists working as advisers in each of the PCGs in the area.
For those GP practises which are involved in the smoking cessation service, the practice
nurses and other staff who provide smoking cessation advice are paid for ‘additional’ time
spent on smoking cessation. They are able to run, on average, a half-day per week clinic and
to follow-up patients who do not attend, which helps to maintain quit rates. This combination
of practice-based and pharmacy-based staff means that patients who present at one or other
location can be referred to an alternative point to access an intermediate advisor if one is not
available at their first point of contact.
In addition to the practice and pharmacy-based services, smoking cessation advice is also
provided by two trained midwives. These midwives visit pregnant women in their own homes
and offer one-to-one support. Other target groups, including young people and members of
Walsall’s ethnic minority groups, did not have extensive contact with the service in year one.
Efforts are currently being made to reach these smokers, both through the existing
intermediate support, and the new specialist service.
29
Case Study Interviews
As the pen-portraits of each of the seven HAZ case studies have demonstrated, the structure
and organisation of the new services varies significantly across the country. Services have
been developed based on local history and circumstances, available expertise and the
perceived needs of the communities within each HAZ. Despite these variations however, the
seven case study sites embarked on a similar journey from April 1999 onwards – to establish,
implement and maintain new cessation services based on national guidelines. In establishing
these services they faced a number of common issues. In our interviews with professionals in
each of the seven sites we addressed a number of themes relating to service development.
Findings highlight a commonality of experience, with some divergence in key areas. The
main themes addressed were:
•
•
•
•
•
•
Staffing
Service Structure
The NRT voucher system
Reaching Target Groups
Monitoring
Central/Local Relations
This section outlines the views of smoking cessation co-ordinators, specialist and intermediate
advisers, pharmacists, GPs (or in some case PCG representatives) and health authority
managers in each of the seven sites. Each of our respondents had a unique perspective which
cannot be easily distilled without reproducing large sections of the interviews. As a result, we
summarise some of their views here, grouped around the themes listed above.
Staffing
Recruiting and retaining skilled staff has been a huge challenge for the Health Action Zones.
We highlighted the issue of recruitment in our interim report. We found that staffing problems
continued to plague the new services in the third and fourth quarter of year one, and indeed
into year two in some cases. The post of smoking cessation co-ordinator was filled in all
seven sites by January 2000, although one of the Health Authorities in Merseyside had an
interim co-ordinator in place (a manager from within the HA) until the post was filled at the
end of year one, in April 2000.
The role of co-ordinator has been crucial in the development of the new services. As one
intermediate advisor said:
Having a key person whose job is dedicated and is very proactive, who gives smoking
cessation work a profile and resources, with support, documentation and training, has been
essential.
The co-ordinators themselves in turn have been heavily involved in trying to recruit specialist
and administrative staff for the services. This has proved difficult and by the end of year one a
number of posts still remained unfilled, primarily for specialist advisers. The most significant
barrier to recruitment was the lack of suitably qualified individuals, with other Health
30
Authorities trying to attract the same individuals to their posts. This problem became more
acute in the Spring of 2000 when the roll-out of services across all parts of the country meant
neighbouring Health Authorities were actively seeking staff. Other factors that hindered
recruitment were the one-year contracts involved, which were perceived as too short and as a
result were extended to three year contracts by some Health Authorities in HAZs. Salaries
were also an issue, particularly in Merseyside where each of the three Health Authorities has
adopted a slightly different model of service provision. One is employing part-time, nonprofessional specialist advisers at a lower rate than a neighbouring Health Authority, with the
result that two of these advisers left to pursue employment in the adjacent area. It may be that
the new services will continue to encounter staffing problems for the foreseeable future, until
the skill-base of suitably trained candidates expands or greater flexibility around an extended
period of in-work training becomes possible. A number of interviewees pointed to the issue of
recruitment as one that is bound to pose challenges for the Health Authorities developing
services in years two and three:
The other thing I would change is having a large section of the population of this country who
are trained smoking cessation advisors because there is a real problem in trying to recruit
staff. I am sure that the Health Authorities that are coming on board now, not that many of
them will have a lot of money to provide advisors, but there is a real problem with finding
people who are in a position to provide that kind of support at that kind of level.
Service Structure
At the end of year one, each of the seven HAZs we visited were still very much in the process
of developing their service structure. Some parts of the service were not yet in place,
strategies to reach particular target groups were still being formulated, and relationships with
other key local agencies were still being developed. Although good progress had been made
in terms of reaching smokers and helping them to set a quit date, a number of issues remained
unresolved, all of which had implications for year two:
•
•
•
The relationship between specialist and intermediate services
One-to-one and group support
The interface with primary care
Specialist and intermediate services
As the pen-portraits and tabular information about the case study HAZs has described, not all
of them were operating an intermediate and a specialist service in year one. The Health
Authorities within Merseyside HAZ were operating primarily a specialist service, Walsall was
operating an intermediate service, and North Cumbria was operating an almost exclusively
specialist service, although small numbers of smokers were seen by an intermediate adviser in
the fourth quarter. From our interviews, it was apparent that the definition of ‘specialist vs.
intermediate’ was still causing some confusion amongst providers, and was viewed as an
obstacle by some respondents. There was consensus that the main aim of the service was to
reach as many smokers as possible using interventions informed by the evidence-base, but
that the form of delivery needed to vary based on local needs. Sometimes the distinction
between what was specialist and what was intermediate was not clear. As one co-ordinator in
Merseyside told us:
31
So in terms of having not just two or three specialists, we have actually got eleven, which has
caused problems in terms of the intermediate service – is it intermediate, is it specialist?
Some co-ordinators and advisers expressed the opinion that the title intermediate services was
stigmatising in that it made services based in primary care and other settings sound as though
they were merely a stepping stone to the ‘higher level’ specialist interventions. In an effort to
move away from this label, Leeds HAZ is using the term ‘registered adviser’ to describe a
professional who had received training, was giving support to smokers in a recognised setting
and could provide NRT vouchers. In many ways Leed’s modification reflects the
recommendations contained in a recent discussion paper written by Ann McNeill and
colleagues in consultation with other cessation experts at ASH (Bates, McNeill, Owen 2000).
Their recommendation is that services that are not designed to provide intensive group
support but nevertheless meet a range of specified criteria should be designated ‘qualifying
services’. These services would be eligible for funding under the Smoking Kills monies as
long as they met the minimum qualifying criteria, but could consist of a range of approaches,
circumventing the current rigid and occasionally inappropriate distinction between specialist
and intermediate levels.
One to one and group support
An additional issue related to service structure is that of the model of intervention used. The
evidence-base does not strongly favour either groups or individual therapy. However, for
specialist services a model of group support has generally been the favoured approach,
particularly for reasons of cost-effectiveness. (Raw et al, 1998, Hajek and West, 1998)1. In
designing services in Health Action Zones, however, the group support model has not always
been the most practical and as a result several of the case study HAZs focussed on one-to-one
provision in the first year of the new services. Indeed, the dominant model of service delivery
across the seven sites was one-to-one support. In three of the seven HAZs (North Cumbria,
Merseyside and Walsall), the service provided primarily one to one support in year one, for a
range of reasons. In North Cumbria, advisers travel to see individual smokers across the
county, often in communities where running a group would not be viable. As one interviewee
in North Cumbria explained:
Because it is so big and the population so diverse this [one to one]method has been seen to be
the most appropriate way to work with people and it has been very successful. Early data
seems to indicate it is very successful.
In Walsall, the early development of an intermediate service built on a large number of
advisers offering support particularly in primary care settings has also involved one-to-one
interventions. The remaining five case study HAZs all offered a mixture of both one-to-one
and group support in year one. In three of the five, however, one-to-one was described by
those we interviewed as the more popular form of service delivery, one which smokers more
readily accepted. As a co-ordinator told us:
When people ring up the service, either on referrals from a GP, or people can self refer, we
offer them the choice, would you like to join a group or would you like one-to-one? We find
that the majority of people want one-to-one. The uptake of groups is nowhere near as good
1
It is worth noting that the updated Thorax guidelines, published in November 2000, acknowledge that this
model of group support may not be practical in some areas, and emphasise that the effectiveness of different
types of interventions will be influenced by local needs and circumstances (West et al, 2000).
32
as we would hope… We have set some smaller groups up in some of the clinics that were
originally all one to one work but smaller groups aren’t terribly successful, because if you get
a couple of people dropping out, its quite de-motivating for the rest of the group.
In Luton, and to a lesser extent in Nottingham, a model of group support proved more popular
than one-to-one provision. Interviewees in Luton described how smokers contacting the
service were offered a choice of which type of support they would prefer, but few were
selecting the one-to-one option. The town hall had been used a number of times for afternoon
one-to-one sessions, but these had not been well attended.
It is important to point out, however, that in the first quarter of year two, follow-up phone
calls with co-ordinators across the case study sites did reveal that most were either
considering or had already introduced group support, based on sheer demand for services.
Demand has risen both due to early successes, specific publicity and perhaps most
importantly due to the introduction of Zyban and the resulting referrals to the service from
smokers who had originally approached their GP for the product. This suggests that the
emphasis on one-to-one support seen in year one may not be sustainable as services grow and
develop and the policy landscape changes.
The interface with primary care
The NHS plan made clear that primary care should have a clear role to play in planning and
delivery smoking cessation services in the future. The Plan states (Department of Health,
2000, pg. 110) that:
…primary care groups will take the lead in commissioning – and where appropriate
providing - [specialist smoking cessation] services, in support of the new smoking cessation
treatments now to be prescribable at practice level.
It is therefore worth examining the relationship between smoking cessation services and
primary care in year one, through the examples provided by our seven case studies. The
picture is extremely varied, which suggests that in some areas of the country a significant
bridge-building or consolidation exercise will be necessary between primary care and existing
smoking cessation services.
By the end of year one, relationships with primary care in the case study sites appeared to fall
into three categories. Some HAZs had explicitly structured their specialist service around
PCG areas, and had developed the service in close contact with PCG representatives. Others
had built up good relationships with the majority of PCGs in their HAZ, had advisers working
in primary care and viewed their relationship with PCGs as collaborative. Services in other
HAZs had experienced difficulties in communicating with PCGs during year one and had
developed a model of service that was largely separate from primary care.
Leeds stop smoking service provides an example of the first type of relationship with primary
care. GPs and PCG representatives have been involved with the service from the planning
stages onwards. There are 5 PCGs in the HAZ. In each PCG, a specialist adviser is deployed
to provide smoking cessation services on a peripatetic basis. In addition, intermediate advisers
are located in primary care settings, with the aim being to have one trained adviser in each
practice across the city.
33
Nottingham’s New Leaf service has also had a positive relationship with the PCGs in the area
but their service structure is not as explicitly linked to PCG boundaries as it is in Leeds.
Nottingham’s specialist service works across the city, with a particular focus on deprived
wards. Their intermediate service is closely linked with primary care as a number of advisers
have been recruited from primary care settings. GPs have however been reluctant to become
directly involved in the service, although several of their practice nurses have been trained as
intermediate advisors. PCG support for the service is strong, however, with four of the six
PCGs in the city providing additional free NRT (a three weeks supply in addition to the one
week under the original voucher scheme) to eligible smokers. As one interviewee in
Nottingham told us:
The PCGs are very interested, clearly with the National Service Framework for coronary
heart disease, that has again put it right at the forefront of everyone’s minds.
Not all smoking cessation services have found it easy to develop a service in partnership with
PCGs however. While it is fair to say that in each of the seven case studies interviewees
mentioned a general reluctance on the part of many GPs to encourage practice staff to be
trained as intermediate advisers, in some HAZs this reluctance has extended to lack of cooperation at PCG level. North Cumbria provides one example of a HAZ in which primary
care has not been a significant player in the development of smoking cessation services.
While all three PCGs are represented on the steering group for the service, very little smoking
cessation work was taking place in primary care in year one.
Specialist advisers in North Cumbria were in some cases seeing smokers in GP’s practices,
but most cessation work was done in other settings and with one exception no practice staff
were providing intermediate services. Indeed, interviewees in North Cumbria expressed some
concern that smoking cessation work that had previously taken place in primary care may
have been reduced or ceased once the specialist service was developed and became known.
GP’s and other primary care staff were perceived as ‘handing the problem over’ to the new
smoking cessation services, rather than complementing it by continuing to provide some
smoking cessation support in a practice setting. One interviewee expressed frustration with
PCG involvement:
…because the three PCG’s are so diverse they have all got their own agendas and it is very
unproductive and I just tend to get very heavily criticised…It is just a waste of time to be
honest whereas to me the members of the steering group should be providing some input
themselves. They should be going back to their primary care groups and saying look what
are we doing in primary care about smoking. What are we doing about data collection but
nothing comes of this…
Another concern expressed was that once PCGs/PCTs are in a position to commission
cessation services as indicated in the NHS Plan, many may cease promoting existing
specialist services.
The NRT voucher system
Findings from our interim report suggested that establishing the NRT voucher system had
been a difficult process for many Health Action Zones. Most HAZs took six months or more
34
to get the vouchers in place, negotiate distribution arrangements with pharmacists and train
advisers in their use. However, by the time our fieldwork in the seven case study sites was
underway (in the spring of 2000) each HAZ had a functioning voucher system and eligible
smokers were receiving one weeks free NRT.
Due to the effort that had been invested in developing a local voucher system, we found some
resistance to the national scheme that has been proposed by the Department of Health from
year two onwards. Existing individual vouchers do vary significantly between HAZs in terms
of the information provided on each and the mechanisms for redeeming them at local
pharmacies or in some cases from advisers in primary care. Thus the prospect of modifying a
scheme that had only just got off the ground was not greeted with any enthusiasm by those we
interviewed. The co-ordinators we spoke to felt that a national voucher and national system
for the provision of NRT should have been agreed during year one. Admittedly a uniform
voucher system may simplify some aspects of setting-up services for Health Authorities
across England, but it will cause short-term upheaval for Health Action Zones. As one coordinator told us:
I am a bit annoyed about this…I have received this thing, at the top it says ‘NRT Protocol’ or
‘Framework’. I have read it through, and it seems quite a good idea, but it could have been a
very good idea if it was given to us a year ago. We have spent thousands and thousands of
pounds on our vouchers…There is no point trying to introduce a new voucher, the
pharmacists have just got used to this one, and it is just going to cause immense problems.
In our interviews we also explored issues of NRT efficacy and impact from the perspective of
those working within the new services. Not surprisingly, the universal view that we described
in our interim report – that one week’s free to eligible smokers was insufficient in
encouraging them to quit - still held. As one co-ordinator told us:
…the clients get very angry about it that they can only have one weeks free NRT, and one of
my advisors had an NRT voucher thrown back at her because the person could only have a
week. We have had ‘phone calls from clients, the administrator has had to deal with clients
who are absolutely outraged that they can only have the weeks free NRT, we have had phone
calls from GPs absolutely outraged and…we have had to say to them, this is not the [local]
scheme, this is the national scheme and its not negotiable.
However, views on one week free are now considerably less important given the commitment
in the NHS plan to investigate the possibility of NRT on prescription from 2001, and the
commitment by the Department of Health to extend the voucher scheme to between four and
six weeks free for eligible smokers. What is perhaps still relevant is evidence from those
HAZs that were already providing more than one week’s free during year one. There are a
number of examples of this, but within the case studies smokers in Walsall and some areas of
Nottingham and Merseyside were able to access schemes which gave them access to four or
more weeks subsidised NRT.
The schemes which provided more than one week’s NRT during year one reveal some
interesting anecdotal findings regarding the efficacy of a longer period of support. In one
small area of Merseyside, up to 12 weeks NRT is funded by an through Single Regeneration
Budget (SRB) scheme until the end of 2000. This scheme has proved a useful link for the
new smoking cessation services as it had a pre-existing voucher which became a model for
the one eventually developed across Merseyside. Some problems have been encountered in
35
obtaining monitoring data for smokers living within the SRB area who are using the service,
but initial results suggest that they are more likely to continue to use the smoking cessation
service and set a quit date than those who are eligible for only one week free. The chair of the
local pharmaceutical committee in the area confirmed that smokers eligible for the extended
free NRT were more likely to attend regularly for the full course of treatment, whereas there
was a much higher drop out rate amongst those using HAZ vouchers. This supports reports
from HAZs providing only one-week’s free that suggests that in some cases between 60-80
per cent of smokers drop out immediately following the receipt of one week free, rather than
persevering.
Yet the extension of one week’s free, as all the research evidence suggests, will make little
difference without adequate support for the smoker. Motivational counselling and contact
with a trained adviser are clearly crucial. Walsall’s extended NRT scheme offers two weeks
free and a further two weeks at half price, building on a project that was in place prior to the
smoking cessation money becoming available. One pharmacist in the scheme has modified
provision slightly to provide three weeks NRT completely free. He has been monitoring the
patients receiving free NRT. Initially he was seeing smokers for an hour on a one-to-one basis
to determine a treatment plan, and then following up this contact with weekly fifteen minute
sessions every week for three weeks, with an additional appointment in week five. Due to
time constraints, he began to see patients at week one and then again at week four, but after
some time he noticed that this was affecting drop out rates. Despite the fact that the NRT was
still free, a number of smokers were not returning to take up weeks two and three. As a result,
he reinstated the weekly support sessions. Walsall’s scheme is a single example, but one
which supports the proposition that the efficacy of NRT on prescription will depend on
adequate support to smokers from trained cessation advisers.
Reaching target groups
In designing and implementing the new cessation services, professionals in Health Action
Zones have made efforts to reach the target groups identified in Smoking Kills – namely
disadvantaged smokers, pregnant women and young people. It was evident from our
interviews, however, that the effort of getting services up and running in a hurry has limited
HAZ’s capacity to think strategically about the best way to reach these particular groups.
Although we will need to wait for results from the next stage of the national evaluation
(which will examine this issue in some detail) to determine whether the new services are
effectively targeting adults living in disadvantaged communities, the perception of
interviewees across the case study sites was that there were some early successes in this area.
All the services were treating smokers who were eligible for free NRT, and in some areas
(such as Merseyside and Camden and Islington), the majority of smokers using the service
qualified for vouchers. This suggests that smokers on low incomes are being reached. In
addition, North Cumbria and Nottingham’s service was designed with the intent of focussing
specialist support on the most deprived wards in the area, which has increased the likelihood
that smokers from these communities are using the service. Nottingham’s service has recently
carried out some research of its own to determine what proportion of smokers using the
service were from the target wards in the city – this investigation found that between 80-90
per cent of smokers accessing the service in the latter part of year one were from deprived
areas.
36
As other research has illustrated, however, the barriers to successful quitting for lower income
smokers are significant (Gaunt-Richardson, 1999, Graham, 1993, Sanders et al, 1998).
Advisers in each HAZ emphasised that the reasons for clients continuing to smoke were
sometimes very difficult to address within the confines of the service available. One
interviewee in Merseyside related the response of one particular smoker:
“Smoking for me has got me through some tough times – both my son and husband committed
suicide, and my daughter is living with a violent partner.” And these social problems are so
profound, and so difficult to reconcile with the numbers game that the Government implies
with its targets.
Advisers emphasised the short time available to them to spend with individual smokers
(usually a twenty or thirty minute appointment) and how this prevented them from “getting
beyond the presenting problem”. In addition, it was apparent that the barriers to quitting faced
by many low-income smokers also acted as a disincentive for the service to invest time and
effort in reaching these groups. Indeed, there may be a fundamental dichotomy between
reaching difficult to access smokers and meeting government targets. The pressure of targets
means that the new services are focussed on reaching as many smokers as possible. The
smokers who are easy to reach are those from more affluent groups, for a number of reasons.
Firstly, all of the case study HAZs accept self-referrals from smokers. While this is good in
practice in terms of maximising opportunity of access, the smokers who are most likely to
ring up a help-line are less likely to be from the most disadvantaged groups. As one
interviewee in Luton put it, the self-referral mechanism does result in ‘more bums on seats’
but may actually contribute to the health divide in terms of improving outcomes for more
affluent smokers who are confident enough or feel enough social pressure to quit to come
forward. Secondly, there have been some early successes in terms of providing support to
smokers in the workplace, in some cases in conjunction with an employer contribution to free
or subsidised NRT. While workplace smoking cessation is important, reaching large numbers
of smokers in employment by default excludes those not in work. Thus the new services face
a dilemma of the need to target services as well as maximise numbers. As one pharmacist told
us: “Its obvious – if you aim at all smokers, the more you have, the greater the success!”
It is perhaps important to point out, however, that although smokers from ethnic minority
communities were not specifically identified in the White paper as a target group, some HAZs
have had early success in reaching these groups. In Camden and Islington, there is a helpline
and adviser support for smokers from Turkish, Kurdish and Bangladeshi communities that has
thus far been very successful. Walsall has also had some success (particularly in conjunction
with one PCG in the area) in reaching smokers from the Asian community through their
intermediate service.
The professionals we interviewed were less optimistic about their ability to reach pregnant
smokers. Although services in all seven case study sites had either recruited midwives as
advisers or developed links with the midwifery services in their area, there was very little
progress in encouraging pregnant women to quit in year one.
A number of barriers to treating pregnant women were identified by those we interviewed.
The first related to basic problems of access. It was generally acknowledged that the single
most effective way to reach pregnant smokers was through services they were already
receiving – primarily midwifery services. However, recruiting a sufficient number of
midwives as advisers or setting up adequate lines of referral between midwifery and cessation
37
services had proved difficult in a number of areas. In North Cumbria, for instance, two
midwives were employed in year one as advisers. These women were hospital-based but
visited pregnant smokers in their own homes. However, they each were able to allocate just a
few hours per week to advising and thus had contact with a relatively small group of pregnant
women. Efforts are now being made in North Cumbria to expand this aspect of the service. In
one health authority in Merseyside, in contrast, the local hospital trust was allocated a portion
of the smoking cessation monies to provide a limited service for pregnant women based in the
midwifery department. However, there was a nine month delay between providing the
funding and appointing a midwife, which affected the ability of services to reach pregnant
smokers in year one. Overall, there was a perception amongst interviewees that links with
midwifery needed to be improved in order to begin to provide an adequate level of service for
pregnant smokers.
A second barrier to encouraging pregnant women to quit smoking was the absence of support
from NRT. Most forms of NRT are contraindicated during pregnancy. This means that
quitting can be particularly challenging for pregnant women, even with support from services.
As one co-ordinator told us:
It is very difficult working with pregnant women. Now there are loads of other issues that
come into play in terms of the pregnancy scenario, but the absence of NRT in that respect is
really noticeable…the health professionals feel very concerned that they don’t have NRT or
anything else to offer, other than verbal support, and I think that is extremely noticeable in
the results we’ve got.
Pregnancy can be a particularly stressful time for women and thus quitting without any means
to reduce their craving for nicotine can be very difficult. Because of these and other factors,
group support can often be ineffectual or inappropriate. Interviewees across the case study site
reported problems in trying to convince pregnant smokers to attend groups. One interviewee
cited the case of a single pregnant woman who had agreed to attend a group near her home,
but had dropped out after one session. Another interviewee told us that pregnant women
phoning the service were often enthusiastic when offered the opportunity to come to a group,
but later decided it was infeasible due to the logistics of getting to a central location (often
with other children to consider) or discussing their smoking in a group setting. Thus it may be
that intensive, one on one support, provided at home, is most effective for pregnant smokers.
But this is a resource intensive form of intervention, which year one services had limited
capacity to deliver.
Monitoring
In several sections of this report we have presented findings from the Department of Health’s
monitoring framework. While this monitoring exercise is yielding valuable information about
the new services, the process of collecting and collating data has proved to be a challenge for
co-ordinators and others working in smoking cessation. We asked interviewees across the
case study sites about the process of monitoring in year one. A number of issues were raised
by interviewees, some of which echoed findings presented in our interim report. These issues
included:
• Tensions between delivering the service and collecting data
• Concerns about monitoring design
• The exclusion of smoking reduction from definitions of success
38
Delivering services and collecting data
As our interim report outlined, smoking cessation co-ordinators across HAZs have found the
process of developing the mechanisms to collect monitoring data difficult and time
consuming. These sentiments were echoed by a number of the professionals, and all the coordinators, whom we interviewed in the case study sites. Obtaining adequate databases to
enter the information has been a challenge, and indeed two of the seven case study HAZs
were still without databases at the end of year one. This meant that monitoring information
only existed in the form of individual sheets which the co-ordinators tallied to produce figures
for each quarter. This was an extremely time consuming and inefficient process. Amongst the
other case study sites, there was concern about the amount of time that administrators were
spending entering data. Administrative support was in some cases insufficient and as a result
the co-ordinators themselves were doing much of the data entry. Overall, there was real
concern expressed about the time commitment required to fulfil monitoring requirements, in
contrast to the time available to provide services to smokers or train advisers. As one coordinator put it:
I would have liked more time to get out and run more clinics and get on with the work that
needs to be done, rather than just doing paperwork, although I appreciate that the paperwork
needs to be done, but there is just the two of us at the moment and it is important that we
don’t neglect the people who want to give up smoking.
Indeed, some professionals felt angry about the burden of monitoring. One senior manager
said ‘We are just feeding the beast’, pointing to the disproportionate amount of data that
needed to be collected in contrast to other health authority/health trust programmes with much
larger budgets.
Collecting adequate data from intermediate services has been particularly difficult for coordinators in year one, as we highlighted in our interim report. These difficulties continued in
the second half of the year and from recent contact with co-ordinators it is evident that
problems are continuing in year two. Most intermediate advisers are health professionals who
have attended a training session run by the smoking cessation service and subsequently
provide support to smokers for a limited number of hours each week. Although monitoring
requirements are addressed in their training, advisers find it difficult to complete and return
all the forms correctly. There are a number of reasons for this. Firstly, the monitoring forms
are not compatible with any existing data collection exercises in primary care, which means
that practice nurses and GPs in particular have been reluctant to use or return the forms.
Secondly, the very part-time nature of intermediate advising means that time is particularly
limited. As a result, advisers have been either partially completing the forms or completing
them but not returning them to the smoking cessation co-ordinator. Finally, some advisers
have only been returning forms relating to the ‘successful’ smokers – i.e. those that they have
seen who have set a quit date and quit at four weeks. This defeats the purpose of the
monitoring exercise and results in inaccurate results for the service overall, putting into
question the impact of intermediate services. It is not clear how these issues can be resolved,
but it is evident that if central monitoring is going to produce evidence about the effectiveness
of the new services, the approach to gathering evidence in primary care and other
‘intermediate’ settings may need to be reconsidered.
39
Monitoring Design
Concerns were also raised across the case study HAZs about what was perceived as the
relatively arbitrary nature of the monitoring exercise. As HAZs were the first to receive
money for the new services, and central government was keen to collect data to demonstrate
success, there is a perception amongst professionals working in HAZs that the monitoring
process was introduced in a great hurry with little consideration for careful design. As one
senior manager said:
My impression is that the whole data collection was rushed in without much forethought and
you know central government has not stopped to think what exactly it does want and why does
it want it. Does it need that level of detail?
Evidence regarding problems with the design of monitoring forms related largely to what
those working in smoking cessation saw as a lack of guidance and clarity on completing
certain sections of the forms. Co-ordinators were also initially unsure about the logistics of
collecting 52 week quit rates. In addition, the perceived discrepancy between quarterly and
annual returns caused problems for co-ordinators. This seems to have centred around age
categories, which were more detailed in the annual returns forms than in the quarterly returns
forms, which made it more difficult for the services to combine their quarterly data for the
end of year return.
Smoking Reduction
Success for the new services is defined by the number of smokers who set a quit date and
subsequently give up smoking. The monitoring framework is designed to collect information
about smokers in order to determine how many, from which groups, eventually become
quitters. What the framework excludes is any recognition of smoking reduction rather than
purely cessation. While the debate regarding the pros and cons of supporting smokers to
reduce their intake has been dealt with elsewhere (Hughes, 2000, Hughes et al, 1999), it is
important to point out that a number of professionals working in the service view reduction as
having some positive benefit, one which should be included in judgements about the overall
success of the new services. As one adviser put it:
The Government wants 50 non-smokers within such and such a time. They ought to accept
that it is equally important to persuade people to cut back…If I persuade someone to cut
down from 60 to 15 a day, is that not a success, looking at risk reduction in CHD etc. Its all
down to number crunching.
It is admittedly difficult to imagine how the existing monitoring framework could be modified
to take into account reduction, or even if it is desirable to do so. What this illustrates
however, is that there may be differing views about what constitutes success for the new
services. While monitoring will produce some evidence about the new services’ ability to
meet overall targets, it cannot provide adequate information about the important contributions
the new services are making to more general health education, awareness raising and smoking
reduction. It will be important for the next stage of the national evaluation to provide evidence
about these broader indicators of success, along with addressing issues of impact in terms of
quitters.
40
Monitoring Results in the Case Study HAZs
As interviews with a range of key informants across the case study areas reveal, developing
and implementing services in year one was challenging. There were a number of barriers to
progress present even in the second half of year one which affected the services’ ability to
reach smokers, encourage them to set a quit date and confirm that they had quit at four weeks.
Table 3 and 4 illustrate the progress that these HAZs made between October 1999 and March
2000 (quarters three and four) in reaching and supporting smokers.
Table 3.
HAZ comparison table for Quarter 3
Quarter 3 Numbers setting quit dates, quit dates at 4 weeks (self report) and 4 weeks
CO validated (for intermediate and specialist services)
Total setting quit dates
HAZ
by 100,000 population
Leeds
0.1
Luton
2.8
Nottingham
4.4
Walsall
25.5
North Cumbria
27.6
Merseyside
29.6
Camden &
Islington
55.6
Quit dates at 4 weeks (CO
validation) by 100,000
Quit dates at 4 weeks (self
report) by 100,000 population population
0.1
0.1
1.1
0.8
3.1
1.3
9.9
0.0
22.6
19.3
14.4
5.6
13.4
6.9
Table 3 presents findings from the quarter three monitoring returns for all seven case study
HAZs and refers to totals for both intermediate and specialist services. Monitoring figures are
presented by 100,000 population, allowing for direct comparison between the HAZs. In the
third quarter, Camden and Islington already had a fairly well developed service that was able
to reach just over 55 smokers per 100,000 population Merseyside, North Cumbria and Walsall
also had some success in reaching smokers between the beginning of October and the end of
December 1999. Leeds, Luton and Nottingham were still establishing parts of their services
and NRT voucher system during that period and saw only a limited number of smokers.
Figures vary, however, between smokers setting quit dates and those actually quitting at four
weeks. Although North Cumbria’s new services saw fewer smokers in Quarter 3 than services
in Merseyside and Camden, a higher proportion of smokers per 100,000 population had
successfully quit at four weeks. In addition, a high proportion of these smokers had their quit
status confirmed by CO validation.
41
Table 4.
HAZ comparison table for quarter 4
Quarter 4 Numbers setting quit dates, quit dates at 4 weeks (self report) and 4 weeks CO
validated (for intermediate and specialist services)
HAZ
Leeds
Luton
Nottingham
Walsall
North Cumbria
Merseyside
Camden & Islington
Quit dates at 4 weeks Quit dates at 4 weeks
total setting quit dates (self report) by 100,000 (CO validation) by
100,000 population
by 100,000 population population
11.8
5.8
4.5
38.6
28.7
21.0
47.9
17.2
13.7
71.6
33.1
0.00
73.8
41.6
28.8
80.3
40.3
24.1
125.7
42.5
19.7
By Quarter 4, smokers in all seven case study HAZs were setting quit dates and the numbers
were considerably higher than they had been in the previous quarter. Again, Camden and
Islington reached the highest number of smokers per 100,000 population, and indeed more
than doubled their numbers in comparison with Quarter 3. As we have mentioned elsewhere
in the report, Camden’s service developed more quickly than those in other parts of the
country as a result of pre-existing knowledge and expertise in smoking cessation in the area,
fewer problems with recruitment, and an effective early strategy that developed services at
both the intermediate and specialist levels. Figures for Camden and Islington also demonstrate
that they had the highest number of smokers per 100,000 population who had successfully
quit at four weeks – although this figure (42 per 100,000 population) reflects a lower
proportion of the number of smokers who originally set a quit date for services in other case
study HAZs. What is also interesting about these quarter 4 figures is the fact that rates of CO
validation for quitters at four weeks vary considerably. As in Quarter 3, North Cumbria and to
some extent Merseyside demonstrate that a high proportion of smokers self-reporting quitting
at four weeks had their quit status confirmed by CO validation, whereas the other HAZs had
very few CO confirmed quitters at four weeks. This probably reflects wide variation in the use
of CO monitors rather than significant variance between self-report and confirmed quit rates.
Although we did not address the issue of the use or availability of CO monitors in our study,
it was apparent from some material in the interviews and commentaries that these were not
being used on a regular basis in some areas, particularly by intermediate advisers.
42
Figure 5.
Total smokers confirming quit status (self report) at 4
weeks per 100,000 population in case study HAZs
(Year 1 - 1/4/99 - 31/3/00)
I
&
C
to
Lu
id
ys
er
se
n
e
ll
sa
W
al
br
um
C
M
N
N
ot
tin
Le
gh
ed
s
am
ia
70
60
50
40
30
20
10
0
Figure 5 illustrates findings from the annual returns submitted by all seven case study HAZs.
Data relating to the number of smokers who had set a quit date in quarters three and four for
these and all other HAZs was presented in Figure 3 and 4 in the first section of this report.
What Figure 5 demonstrates, however, is the number of smokers who reported that they had
managed to quit after four weeks. Again figures are shown by 100,000 population to allow
comparison across HAZs. Camden and Islington still demonstrate the most progress in
reaching and retaining smokers across their HAZ, with 61 smokers per 100,000 population
successfully quitting at four weeks. In contrast with the data in Table 3 and 4 above however,
Luton also demonstrates progress in year one overall with 59 quitters per 100,000 population
at four weeks. Rates for North Cumbria, Walsall and Merseyside also compare favourably,
with Nottingham and Leeds further behind, again largely as a result of slower development of
services in year one.
Figure 6.
Percentage of smokers setting a quit date in case study
HAZs in year 1 who had quit at four weeks (self report)
90
80
70
60
50
40
30
20
10
0
C& I
Nottingham
Walsall
Merseyside
Leeds
N Cumbria
Luton
Figure 6 presents an alternative analysis of monitoring figures for year one that illustrates that
recruiting larger numbers of smokers to the service may not be the only measure of success
43
that should be considered for services in an early stage of development. Figure 6 illustrates
the extent to which HAZs were successful in supporting the majority of smokers who
originally set a quit date to maintain their quit attempt, resulting in quitters at four weeks. The
Figure shows that, despite Camden and Islington’s success at recruiting a larger proportion of
smokers by population, they were less successful than other services in retaining those
smokers and producing self-reporting quitters at four weeks. Thus 30 per cent of smokers
originally setting a quit date in Camden and Islington had quit at four weeks, compared with
50 per cent in Leeds and 80 per cent in Luton. These figures suggest that although Luton
recruited a small number of smokers in year one relative to other HAZs, they did achieve
considerable success in supporting these smokers to sustain their quit attempt.
However, these statistics are difficult to interpret for two reasons. Firstly, the mix of specialist
and intermediate services varied between Health Action Zones and these differences could
have influenced outcomes. Secondly, some Zones such as Camden and Islington paid
intermediate advisers for each completed monitoring form, whereas others did not.
Perversely, this could have created an incentive for more inclusive coverage of monitoring
non-successful quitters where payment was made. At this point in time we cannot be sure to
what extent variation in the mix of services and payment mechanisms for monitoring has any
impact on the data available, but it is an issue that merits closer investigation in the future.
It should be pointed out that the proportion of smokers quitting at four weeks is a very early
indicator of progress, as many smokers return to cigarettes following an initially successful
quit attempt. It is also worth noting that four week quit rates of even 30 percent, as reported
by Camden and Islington, are as high or higher than those reported for specialist interventions
in clinical trials (Raw et al, 1998). Thus all seven case study HAZs were making good
progress at the end of year one in encouraging a significant proportion of smokers to sustain
their quit attempt beyond an initial few days to four weeks or more.
CONCLUSION
The opportunity to lead the way in developing new smoking cessation services in response to
Smoking Kills was taken up with great enthusiasm by Health Action Zones. Perhaps
inevitably with a new service developed at great speed in response to Ministerial expectations
there have been a number of teething problems. Many of these issues, although by no means
all of them, were resolved during the course of 1999/2000. Nevertheless, what stands out as
most noteworthy is the very considerable progress that has been made by Health Action
Zones in developing new smoking cessation services. By the spring of 2000 all Health Action
Zones had put in place a range of services that were beginning to reach smokers and help
them to set quit dates and in many instances to stop smoking.
What is also apparent is that smoking cessation services are being developed in many
different ways that reflect local needs and circumstances. The challenge for Health Action
Zones was to make the most effective use of the human and financial resources available to
them to put services together in a sustainable way that met the needs of their populations. We
have provided a number of illustrations in this report of the ways in which Health Action
Zones have responded to the opportunities they have been given. Some made faster progress
than others, but that is not surprising given the very variable contexts and constraints facing
different areas. The important point is that by the end of the first year very real progress was
being made across the board.
44
Health Authorities within Health Action Zones will continue to develop of their smoking
cessation services in the next few years. But all HAs in England have now joined the zones in
pursuing key parts of the agenda set out in Smoking Kills. What implications can be derived
from this report that might help to influence the future development of the expanded range of
smoking cessation services?
We have identified a large number of issues in this report. Many of them will be resolved with
the passage of time. But one clear message will continue to be important for any centrally
managed initiative that is implemented locally. Local agencies often have enormous
reservoirs of enthusiasm and expertise that can be tapped to pursue worthwhile social
objectives such as those set out in Smoking Kills. However, the paramount importance of clear
communication between policymakers at the centre and local implementation teams should
never be underestimated. Clear and consistent messages about what is expected and possible
and why are of critical importance. When new services are developed at speed there are
frequently failures of communication. This is not in itself terribly surprising. What is
important though is to resolve misunderstandings as quickly as possible. We believe that
clearer messages are now being communicated and there is every reason to believe that
services will continue to be developed within a clearly understood policy framework.
However, continuing vigilance is called for.
One example, where further efforts are required is in relation to central requirements about
monitoring. As we have highlighted, some people are still not persuaded of the value of
collecting substantial amounts of data about users of smoking cessation services. But it is
critical that they should. If Ministers are to be convinced that further investments in smoking
cessation represent good value for money then they need evidence that the new services are
having a beneficial impact. This will be impossible without good monitoring data. Moreover,
the data need to be of high quality and include information about all service recipients. Now
that services are being established, and many of the early problems that we have described
have been ironed out, the next big challenge is to identify what kinds of services work best for
what kinds of people in what kinds of circumstances. This is as much of a challenge for local
managers as it is for evaluators. The whole community of smoking cessation policymakers
and professionals has a collective responsibility to ensure that questions of impact and costeffectiveness can be addressed. But people do need to be persuaded and in our opinion the
Department of Health would do well to put real and continuing effort into making an effective
case for improving the quality of monitoring systems. In the meantime, researchers also have
a responsibility to try to learn practical lessons about important new public services. We
conclude this report with some thoughts on how this can be achieved in the future.
Next Steps
During the course of 2000 two new research studies have been commissioned to investigate
the further development of new smoking cessation services in all English health authorities.
One of these studies – commissioned by the Department of Health- will be lead by Professor
Ken Judge at the Department of Public Health, University of Glasgow and the other –
commissioned by Trent NHSE Region- will be managed by Dr Tim Coleman at the
Department of General Practice, University of Leicester. However, both studies will involve a
number of other colleagues and they have been designed so that they dovetail closely with
each other.
45
The aim of these new evaluation initiatives is to continue to inform national policy. By
addressing the formation of smoking cessation services across all health authorities, and
examining the range of development, implementation and outcome issues associated with the
new services, the two projects will place findings relating to the new services in a broader
policy context.
The three key aims of the studies are:
• To determine what has been achieved through additional investment in smoking cessation
in terms of the impact on smoking throughout the population, with particular reference to
the target groups identified in Smoking Kills;
• To determine what has been achieved through additional investment in terms of the
development of sustainable, cost effective services; and
• To identify what lessons can be learnt for future smoking cessation policy and practice.
In addressing these three research aims, the studies will focus on particular issues, including:
service and organisational issues (such as types of services funded and how they relate to the
evidence base, targets for particular population groups, partnership working and community
involvement); service user's views; issues of impact and attempts to quit; and providing an
economic perspective of the smoking cessation strategy as a whole.
One of the most critical aspects of the new research projects, however, is to investigate the
impact of cessation services on desired smoking-related outcomes such as delivering services
to disadvantaged groups, helping smokers to set quit dates and achieving a reduction in
smoking rates. It is intended that these issues should be investigated in three distinct ways.
•
The first aim is to assess the extent to which the new smoking cessation services make
a significant contribution to promoting equity of access to health care and to reducing
inequalities in health by delivering services to people living in the most seriously
disadvantaged communities. This issue will be investigated through a detailed analysis
of service recipients in two NHS regions by using individual postcode data to assess
the extent to which services are being delivered to smokers in the most disadvantaged
areas using a range of small area deprivation indices (especially the newly-released
2000 Index of Deprivation).
•
Secondly, it is planned to exploit a number of data sources – including national
monitoring data - to undertake a comparative, multivariate analysis at an aggregate
level of the extent to which health authorities are able to achieve desirable outcomes
in relation to smoking cessation. The aim is to identify the degree to which indicators
of service provision have a statistically significant impact on smoking-related
outcomes after controlling for baseline prevalence rates and other characteristics of
health authority areas such as indicators of socio-economic composition and more
qualitative factors derived from national surveys of key actors within health
authorities.
•
Finally, attempts will be made to build close working relationships with a selection of
smoking cessation co-ordinators in a reasonably representative sample of areas to
develop a more comprehensive minimum set of data requirements (than that
recommended by the DH) for individual service recipients so that it is possible to
undertake individual level statistical analyses of the degree to which different types of
46
service increase the probability of achieving desirable smoking outcomes after
adjusting for individual characteristics known to be associated with the likelihood of
successful quitting.
A number of reports will be published on these and related topics during the next two to three
years and they will be disseminated as quickly and as widely as possible.
Acknowledgements
This work was funded by the Department of Health. The views expressed in this report are
those of the authors and not necessarily those of the Department of Health.
Comments on an earlier draft of this report were gratefully received from colleagues within
the Department of Health, and also from Ann McNeill, who provided a number of valuable
suggestions.
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