And the smoking ban played on

When Smoking Kills was published in 1998, 32 per cent of adults in Scotland and 28 per cent of adults in England smoked. There were concerns that the decline in smoking rates over the preceding three decades was levelling out. Rates varied according to gender, social class and location: they were higher among men, manual workers and in areas of high social deprivation.

Smoking cessation services have since made steady progress towards achieving the 2010 targets for adult smokers of 22 per cent in Scotland and less than 21 per cent in England. By 2004 Scotland was down to 26 per cent and England to 22 per cent by 2006.

The bans on smoking in enclosed public places introduced in both countries are likely to have boosted recent quit rates. In England from April to December 2007 (the three months before and six months after the ban), the successful quit rate at four-week follow-up was up 22 per cent on the same period in 2006. Smoking cessation services also reported huge increases in workload in the months leading up to the bans.

Given the long-term development of many smoking-related diseases, it is too early to say how lower rates of smoking have affected their incidence. However, there have been encouraging signs that the smoking bans have had an immediate positive effect, although more research is needed to confirm the extent to which they are related to the bans.

In Scotland annual hospital admissions for heart attack have gone down by 17 per cent since the ban was introduced in 2006; nationwide figures for England are not yet available. But a survey of a number of NHS trusts revealed that many had experienced similarly positive results: one had seen a 40 per cent reduction.

Weathering the ban

While smoking bans may have prompted many people to quit, the groups of smokers standing outside public buildings suggest the main beneficiaries are probably non-smokers. And the sight of people enduring the worst weather conditions to smoke clearly illustrates the importance of offering the support of effective smoking cessation services.

Research consistently shows these services to be a cost-effective way of improving public health. An analysis by John Stapleton of the Institute of Psychiatry published in 2001 found that they are at least 40-50 times better than the National Institute for Health and Clinical Excellence benchmark of£30,000 per quality adjusted life year. Dr Stapleton concluded that smoking cessation was probably the most effective way the NHS spends money and asked why it did not spend more in this area.

The Department of Health appears to have recognised the logic of this argument and has invested heavily in smoking cessation initiatives over the past few years. Success rates are variable, but those showing the most impressive results share certain characteristics.

One main factor is the attitude of the commissioning primary care trusts, as Miriam Bell, service manager at Roy Castle Fag Ends, a community-based stop smoking service funded by Liverpool PCT points out: "We've had huge support and investment from the PCT, which has been crucial to our success."

Julia Thomas, senior public health manager, tobacco control for Medway Stop Smoking Service, funded by Medway PCT, agrees. "We have received good support from the PCT, and now that NHS finances seem to be in better shape, we are getting money to expand."

Offering a client-led service is also crucial. This means services must respond to local needs in a flexible and accessible manner. Clients need to be able to access the type of support that meets their needs at the time they decide to quit.

Immediate service

"This is what 'abrupt quitters' need," says Ms Bell. "These are people who wake up one day and think 'I'm going to stop smoking'. It's no good telling them they have to wait 10 weeks until the next programme with places available."

Fag Ends runs 60 group sessions a week in a wide range of settings. Fifty-five sessions are on a rolling programme so clients can walk in without an appointment and obtain immediate support; the remaining five sessions are one to one.

Another service offering a rolling programme of drop-in sessions has come up with a way of enabling clients to vary the sessions they attend but maintain continuity of care. "Clients are given a treatment card so our advisers can see exactly what they have received," says Jan Holding, who manages the service funded by Blackburn with Darwen PCT. "The card also acts as a kind of passport so they can go to any session."

The sessions split into three groups to meet the needs of different clients: first-time attenders, follow-ups and clients using a nicotine receptor partial agonist, which reduces withdrawal symptoms. The service does not stipulate how many sessions clients can attend.

"They can come for as long as they need and can return at any time - in fact they are encouraged to do so," says Ms Holding. She does not subscribe to the NICE view that clients should not be able to access services again for six months after a quit attempt. "I think that's cruel - if they relapse we'll take them back as soon as they want to come. You have to offer people support when they want it."

Offering specific services for black and minority ethnic groups is important. In Liverpool, Fag Ends is working with local mosques to organise a smoke-free Ramadan - an ideal opportunity to motivate people to quit.

Minority use

Some minority groups use tobacco differently. In South Asian communities tobacco is often chewed, so stop-smoking messages can be meaningless. This highlights the importance of making services culturally sensitive, rather than assuming language is the only issue to be addressed.

Medway's expansion enabled Ms Thomas to recruit a Polish adviser and one who speaks five Asian languages. "This means we can cater for the two biggest minority groups in the area, and I can already see the difference they are making," she says.

Most services work hard to offer a range of venues, typically health and community centres and public facilities such as libraries and town halls. They also go into workplaces if employers are receptive to the idea.

Medway has taken on board the importance of using settings in which clients feel comfortable and runs sessions in local pubs and clubs.

"These are very popular with a lot of clients," says Ms Thomas. "They find them a sociable way of accessing services with their friends, while the pubs and clubs appreciate the groups bringing in customers."

With many licensed premises claiming their income is still affected by the smoking ban, any initiative that persuades customers to give up is also likely to be welcomed.

Fag Ends persuaded a shopping centre to allow its advisers to use an empty shop unit once a month. The smoking cessation service also partnered with Pfizer on the Serious Quitters campaign when it visited Liverpool, where they ran one-to-one sessions providing support and practical advice on treatment options.

Toughest groups

Timing of sessions can be as important as venues. Fag Ends offers early sessions at 8am and evening sessions up to 8.30pm. Its workplace programme has even offered sessions at 1am to Royal Mail night shift workers.

While the services are showing real success in helping people to stop smoking, as more quit, the remaining smokers are likely to be the toughest groups to help. These are the hard-to-reach groups and the heaviest smokers, both of which often live in socially deprived areas.

"Health inequalities are a major challenge," says Ms Holding. "There is a core of smokers, many living in deprived areas, who use a lot of tobacco - often in roll-up form. That's where we do well: we're very available and accessible both in our sessions and treatment approaches.

"We offer pre-quit oral nicotine replacement therapy; we have been doing so for eight years and it is extremely effective. It gives these clients support in cutting down, increases their confidence and is a chance to learn about their smoking, and it motivates them."

Blackburn with Darwen's four-week quit rate is around 70 per cent; at 52 weeks it is around 50 per cent. Ms Holding sees this as a far more realistic assessment of the quality of service. "I think all services need to move towards using the 52-week rate as the true measure. Four weeks really isn't very meaningful."

Challenge ahead

The smoking cessation services all have challenging work ahead to meet their 2010 targets. They face "competition" from illicitly imported tobacco, which sells at around a third of the price of the legal product. This removes the economic factors that may motivate less affluent smokers, and also means smokers taking risks in other unknown substances such as cow dung and sand in addition to tobacco.

Young people are also far more likely to be able to afford illicit tobacco, and this is the group that cessation services want to prevent from taking up smoking in the first place. To persuade them to avoid tobacco, health promotion messages must be engaging and age-appropriate. This means catering for a wide range of developmental stages - in Liverpool, one of Fag Ends' advisers is working with children as young as five.

Despite these challenges, services remain optimistic. Ms Holding sums the situation up. "We're not complacent, we have to keep on top of things, but as long as our commissioners continue to invest in the service, we won't have any problems meeting our 2010 targets."