The government is determined to tackle smoking, but there are doubts that the development of smoking cessation services is being tackled in the right way. Catherine Adams and colleagues explain

Smoking is the largest single preventable cause of death and disability in the UK, causing more than 120,000 deaths each year.

Saving Lives: our healthier nation identified smoking as a major risk factor for deaths from cancer and coronary heart disease and stroke.

The government's strategy to tackle smoking was published in the 1998 tobacco white paper, Smoking Kills, which put forward a wide range of measures to reduce the prevalence of smoking overall and to improve health.

A central component of the reforms is the development of smoking cessation services. These are targeted particularly at economically disadvantaged smokers, and at other groups such as pregnant women and young people.

Funds of up to£60m are to be made available to health authorities over three years to develop smoking cessation services. In the first year (1999-2000), however, the resources were limited to health authorities in health action zones in an attempt to target smokers living in deprived communities.

The guidance to health authorities advocates services based on brief interventions, and a more intensive specialist service. A further key component is the use of nicotine replacement therapy based on evidence of its effectiveness in helping smokers to quit. HAZs are expected to put in place arrangements for the distribution of one week's free NRT, available to those who qualify for free prescriptions.

The development of smoking cessation services is being monitored by the Department of Health, which expects HAs to submit quarterly returns compiled from a basic database. The DoH also commissioned a one-year study to look at a range of strategic issues relating to service development. Here we present preliminary findings relating to the introduction of smoking cessation services in HAZs and examine the implications for the future development of such services, which are being introduced to all health authorities from April 2000.

Monitoring implementation of cessation services was conducted on two levels. First, a broad mapping exercise was carried out which examined the first and second quarter monitoring returns, and the plans and commentaries that accompanied the returns.

Face-to-face, semistructured interviews were conducted between November 1999 and February 2000 with smoking cessation coordinators in all 26 HAZs.

All the interviews were audio-taped and transcribed verbatim .They were then analysed thematically by two researchers to ensure reliability. This involved deconstructing each interview to identify key concepts and coding categories.

The concepts identified were then integrated into themes.

HAZs are area-based partnerships established in England to pioneer creative approaches to tackling health inequalities and modernising services.

The first wave of 11 HAZs began life in April 1998, followed by the launch of a further 15 zones a year later. While all HAZs share problems of deprivation, poor health and high smoking rates, they vary considerably in terms of size, organisational complexity and population profile. The differences between HAZs have important implications for assessing the effectiveness, efficiency and sustainability of smoking cessation services.

Before the publication of the white paper, health agencies were already providing smoking cessation services in some communities. In others, however, there was little or no smoking cessation activity. Three basic categories of pre-white paper provision were identified: a total of seven HAZs had no pre-existing provision beyond opportunistic advice offered by health professionals; 10 of the HAZs had some smoking cessation activity, usually provided by health professionals who had received smoking cessation training; and six HAZs offered more established smoking cessation services.

Starting points These varied starting points have had an impact on the speed with which HAZs were able to get services up and running. For example, even moderate levels of existing provision gave HAZs an advantage, in that they already had professionals with previous experience of smoking cessation services on which they could build.

The HAZs that reported little or no smoking cessation activity before 1999 were mostly those with large rural areas, or small HAZs in urban areas without extensive secondary care services. Developing smoking cessation services in areas with no pre-existing provision was an important challenge for those planning and implementing services. Although pharmacists, GPs, practice nurses and others had been providing brief advice, there was little or no local expertise to build on in terms of setting up specialist services. The smoking cessation co-ordinators in these areas felt they had been disadvantaged due to this lack of local experience and found the tight timescale for service development particularly difficult.

Getting started It was expected that dedicated smoking cessation staff would be appointed to run the services from April 1999.

The key appointment would be that of a smoking cessation co-ordinator. Services were expected to be operating by June 1999.

But staffing the services has proved difficult for most HAZs. By June 1999, only 10 HAZs had any new staff in position and, by February 2000, 20 per cent of specialist staff and support staff posts remained unfilled. The inability of HAs to get staff in place quickly has been an important factor in the slow development of services.

Delays in appointing dedicated staff can be attributed to a number of causes. In areas where there was little, or no, established smoking cessation services structure, developing a strategy and plan for the service delayed the process of recruitment. In addition, the short-term nature of the funding available limited the attraction of the post for some qualified candidates and contributed to recruitment difficulties.

Service structure and development The DoH guidance requires HAs and their primary care groups to develop local strategies for smoking cessation services in partnership with local authorities and other agencies.

In reality, few HAZs were able to consult widely with other agencies while developing their plans, and some have managed to launch their service with little or no involvement from PCGs in the area. The biggest barriers to inter-agency planning were the time frame for developing the services and problems due to the early stage of PCG development.

The initial guidance outlined an appropriate structure for the services, firmly rooted in the evidence base, 3and structured around opportunistic smoking cessation interventions, and a dedicated specialist smoking cessation service delivering more intensive interventions.

However, a further round of guidance was issued to HAZs in June 1999 that introduced a third level of intervention. These intermediate interventions were described in this document as those that provide support on a 'one-to-one basis by specialist practitioners who will have undertaken some form of accredited/recognised training'.

The perceived discrepancy between these two sets of guidelines appears to have caused considerable confusion in some HAZs. The distinction between intermediate and specialist interventions was not fully understood.

Whether or not these issues of definition will make much difference in terms of the future success of services is debatable.What is clear is that there was a lack of clarity at the developmental stage.

Disadvantaged groups HAZs are required to focus their smoking cessation efforts on disadvantaged groups, young people and pregnant women. As a result of the considerable variation in levels of deprivation , even with in zones , many have chosen to adopt a selective approach to the use of resources, targeting programmes and projects at the most deprived wards. This selective approach is being used within smoking cessation programmes to focus more resources on reaching disadvantaged smokers.

It is not yet clear how consistent HAZs have been in translating that approach to influence service configuration, or what type of coverage they are achieving.

Even at the time of writing, in the spring of 2000, some HAZs are still in the process of recruiting staff and setting up systems to distribute NRT. It is doubt fu l that services are being particularly successful in reaching disadvantaged smokers in any numbers.

Work to target pregnant smokers and young smokers is still in the planning stages in most zones. Despite these delays, there are some encouraging signs in terms of service configuration.

Several HAZs have specifically appointed part-time advisers to the specialist service who live in priority wards. Another group of HAZs are locating group sessions in community halls or other appropriate settings in deprived areas.

HAZs are required to submit quarterly monitoring returns to the DoH. These returns will provide evidence of smokers setting quit rates in HAZs. But because of delays in setting up the service and establishing the NRT voucher scheme, smokers did not begin using the service in most areas until the autumn of 1999.Thus, it is not surprising that 11 HAZs submitted a nil return for both the first and second quarters. The table (right) shows a breakdown of the number of HAZs with smokers setting dates for quitting smoking.

Even when the number of smokers using the services increases it may still be difficult to assess the impact of the scheme. Three issues are worth noting.

First, there have been problems collecting data in multiple HA HAZs because of the difficulty of coordinating the scheme across a number of HA areas.

Second, there are gaps in monitoring at the intermediate service level. This is mainly because advisers see smokers in a number of settings and, although in some HAZs they receive a fee for each monitoring return completed and returned to the specialist service, there are concerns that not all advisers are doing this consistently.

A final issue in relation to monitoring concerns the definition of quit rates. Defining a successful attempt to stop smoking can be problematic. The guidance defines a successful quitter as someone who has not smoked for two weeks after the initial quit date, but there has been confusion about how this definition should be interpreted.

Research evidence has shown that most smokers lapse before finally succeeding, which implies the need for flexibility within the monitoring framework in terms of who is defined as a successful quitter.

5The commitment given to cessation services in Smoking Kills was widely welcomed, but in retrospect it seems clear that it promised too much too quickly. In particular, there have been a number of barriers to progress in developing the smoking cessation services (see box above right).

Two particular problems stand out. The first concerns the timescale for setting up services. There was an expectation that services would be seeing clients, and that quit dates would be reported in the monitoring return for April to July. This appears to have been particularly problematic.

Before smokers could obtain support and NRT from the specialist services, a range of developmental activities had to take place. Setting up the service infrastructure involved tangible activities such as hiring staff and locating premises, as well as less easily measured but equally important activities such as network and relationship building between individuals and agencies. Reconciling guidance and the evidence base with local knowledge and practice has also been a challenge. Co-ordinators and others are finding a number of elements in the recommended service structure difficult to implement. These appear to fall into three main categories: problems establishing specialist clinics according to the recommended Maudsley model; issues concerning the emphasis on group support in the service guidelines; and concerns about limited opportunities to explore innovative approaches to smoking cessation.

The research evidence does demonstrate the success of the Maudsley model in encouraging smokers to quit. The model involves clinic-based support for smokers in small groups, commonly consisting of around five hour-long sessions with a smoking cessation specialist over one month, plus follow-up. However, its direct application to smoking cessation interventions across the country is being questioned by those faced with the task of developing services.

Finally, while many aspects of the guidelines have been welcomed in HAZs, there is a concern that useful and innovative local solutions may be subsumed in a larger, more rigidly structured set of services. North Staffordshire's project treating gay smokers, for instance, has no existing evidence base to build on, but may prove extremely successful and provide examples for similar efforts in other parts of the country.

Ifthe results are encouraging, it will be important for local solutions to be examined and lessons disseminated as new services develop. HAZs themselves are intended to be trailblazers for new approaches to tackling health problems. It will be essential to balance this capacity for innovation with the delivery of effective and sustainable smoking cessation services in the months to come.

There are some important lessons from this review for a government committed to modernisation at what often appears to be breakneck speed. Real and sustained results will not be achieved unless sensible foundations are laid at an early stage of development.

The understandable pressure to gather evidence about the impact of smoking cessation services could be self defeating unless careful thought is given to obtaining a better understanding about the process of designing and implementing service delivery systems.

Barriers to progress

Lack of clarity about the organisation of services.

Confusion over distinction between intermediate and specialist interventions.

Range of problems in setting up the voucher system for NRT and then supplying NRT to eligible smokers.

Establishing monitoring systems.

Involving PCGs and other agencies in planning and delivering services.

Recruiting and retaining qualified staff.

Key points

The government is making£60m available to develop smoking cessation services over three years.

This year's funding is concentrated on health action zones where progress has been slow.

The cost of nicotine replacement patches is significantly more than many smokers spend on cigarettes.

REFERENCES

1Calum C. The smoking epidemic. Health Education Authority, 1998.

2 Bauld L, Judge K. Health Action Zones. Health Variations, ESRC 1998; 2: 10-11.

3 Raw M, McNeill A, West R. Smoking Cessation Guidelines for Health Professionals: a guide to effective smoking cessation interventions for the health care system. Thorax; 53: (supplement (1): S1-S9)

4 American Psychiatric Association. Practice guidelines for the treatment of patients with nicotine dependence. American J of Psychiatry; 153: (supplement, 1-31).

5 Hajek P, West R. Treating nicotine dependence: the case for specialist smokers' clinics. Addiction; 93: 637-40.

6 Marsh A, McKay S. Poor smokers . Policy Studies Institute, 1994.

Nicotine replacement therapy In the first year of smoking cessation services, HAZs were expected to put in place arrangements for the distribution of one week's free NRT, available to those eligible for free prescriptions.

However, negotiating the supply of NRT with local pharmaceutical committees and setting up the voucher system for its distribution has proved complicated, and has led to significant delays. Changes to regulations governing eligibility has also led to confusion over who is entitled to one week's free treatment.

Moreover, the cost of NRT is significantly higher than the price many smokers are paying for cigarettes, particularly given the wide availability of black market tobacco. For a 20-a-day smoker, for example, a seven-day supply of Boots own brand patches costs around£16.49.

Co-ordinators also pointed to the social factors that research has shown preclude NRT from being an acceptable substitute for tobacco, particularly among unemployed or low-income smokers.

6These factors, when combined with the cost to smokers after the first week, made co-ordinators highly sceptical about the current policy's potential.