Hull and East Yorkshire was among the first wave of health action zones with funds to deliver a smoking-cessation service. But within a few months of the service being launched - on 1 November 1999 - it was hit by politics, press and pills.We needed to respond to changes in policy from the Department of Health, a high-media profile and a new pharmaceutical product for which there was public demand.
We have rolled with the punches and set in place a whole-systems approach to our service. The outcome has been a robust delivery mechanism capable of meeting the needs of community groups within our area and sufficiently responsive to cope with the demands from external sources.
In October 1999 we set up training sessions for health professionals to raise the profile of smoking cessation. This also gave us the opportunity to present details of the smoking-cessation service and actively to seek referrals.
Working with the media We joined forces with the Hull Daily Mail to launch the 'Millennium Trash the Ash' campaign. The campaign recruited readers who wanted to quit smoking as a new year's resolution and tracked their progress in newspaper features throughout the year. It was also used as a vehicle to launch a free telephone information line, giving details of the clinics. In order to target younger smokers, we launched a radio campaign in February 2000, via the local commercial radio station, Viking FM.
We had started with nine clinics across the health authority area, employing one adviser.
Anticipating an increase in demand brought on by the newspaper campaign, we employed a second smokingcessation adviser in order to offer more clinics. These were soon filled and by the end of January both advisers were working at full capacity.
We launched a tobacco-control strategy for the area in March 2000.
This included a 10-point action plan and listed the priority groups to be targeted and potential partners for the HA in tackling smoking.
The Department of Health introduced targets for HAZ smoking-cessation services in April. This meant that a more stringent recording and follow-up procedure was needed. It also became obvious that a patient recruitment drive was needed.
May saw the appointment of a research fellow, to make sure the programme was evidence-based.
GlaxoWellcome launched Zyban in June 2000 to health professionals in the usual way but benefited greatly from media interest in the product. The HA received a number of calls from members of the public asking where they could obtain Zyban.
Impact on service Calls to the information line dramatically increased, from 24 calls in May to 89 calls in June, 75 per cent of which came in the last week. In July telephone enquires increased 400 per cent and there was a large increase in visitors to the drop-in clinics.
August saw the peak in demand (411 calls), with a small decline in the number of calls in September (397 calls). Five times more calls were received between July and September (95 per cent of which request information about Zyban), than in the whole of the previous six months (see figure 1).
The launch of Zyban had a major impact, not only on the smoking-cessation service but also on health professionals working in primary care. The directors of public health and primary care sent out a letter of guidance to GPs on prescribing. This letter urged the use of the smoking-cessation service in conjunction with the drug.
The effect of this guidance letter can be determined by examining the referral routes of callers to the freephone number. In the first quarter of the year only 17 people calling the information line were referred by their GP. This pattern looked set to continue into the second quarter of the year, but we started to see an increase in GP referrals in the last few days of June. This resulted in 64 GP referrals to the service by the end of the second quarter.
In the third quarter 1,012 calls were received as direct referrals from GPs.We believe that this was directly attributable to patients seeking Zyban and not to increased activity from GPs. This is supported by a recent study of GP consultations which showed that 'to avoid confrontation with patients, GPs tend to restrict advice-giving to situations where patients present with smokingrelated problems'.
1Demand on the service became so great that by August we were forced to suspend the drop-in clinic sessions due to the number of people attending.
They were changed to group sessions and additional clinics were set up. A volunteer adviser was taken on to help cope with the increased demand.
The Department of Health announced in August that it would reimburse the cost of up to four weeks' nicotine replacement therapy, a change from its policy of only one week.
In the first six months more clients attended clinics than called the helpline. For the period January to March, 96 calls were received, 120 clients setting a quit date, with 35 per cent (42) remaining abstinent at four weeks. The second quarter of the year (April to June) saw an increase in calls (140), with 153 clients setting quit dates, 73 (48 per cent) of which were abstinent at four weeks follow-up.
Figure 2 shows how the public's interest in smoking cessation was stimulated, with a dramatic effect on the volume of calls to the freephone information line (1,148 calls). This was successfully translated into a fivefold increase over the previous three months in the number of clients setting a quit date (778). This resulted in 374 clients remaining abstinent at four weeks follow-up achieving a 48 per cent abstinence rate.
Although these results have not shown an increase in the ratio of those abstinent at follow-up to those setting quit dates, the absolute numbers of clients giving up smoking has increased substantially. It is interesting that Zyban appears not to have affected the abstinence percentage rates of the service users.
This data seems to suggest that the particular pharmaceutical product is not an important factor when compared to the level of support available.
The increase in GP referrals to the smokingcessation service shows that a clear message had been delivered and that a consistent policy towards the prescribing of Zyban had been achieved. The data also suggests that more GPs are realising the 'exceptional potential in each primary care consultation'.
2This is important as there is strong evidence that advice from the GP is more effective than from other health professionals.
We were warned of the potential for high media coverage of Zyban and the public interest that it would generate.
5But perhaps the delay between this warning and the launch of Zyban led to health planners being unprepared for its impact. In order to avoid such situations again, HAs and primary care trusts need to be more aware of the potential impact of the launch of new drugs with similar public interest.
Pharmaceutical companies and HAs are in a unique position to work with the media when new products are launched. The media's influence can be harnessed, as we showed in a relatively small way with the support of our local newspaper.
The NHS may be seen as the leader in service delivery, but it must cast the net wider to tackle smoking at its roots.
Experience with our smoking-cessation service, shows change can come from any direction and often with little warning and we should not underestimate the influence of the media.We should be prepared to cultivate its power to promote the services we provide.
REFERENCES
1 Coleman T, Wilson A. Anti-Smoking Advice from General Practitioners: is a population-based approach to advice-giving feasible? Br J of General Practice, 2000, 50, 1001-1004.
2 Stott N, Davis, R. The Exceptional Potential in Each Primary Care Consultation. J of the Royal College of General Practitioners 1979; 29: 201-205.
3 Wood D et al. Randomised Controlled Trial Evaluating Cardiovascular Screening and Intervention in General Practice: principal results of British family heart study. Br Med J 1994; 308: 313-320.
4 Imperial Cancer Research Fund OXCHECK Study Group. Effectiveness of Health Checks Conducted by Nurses inPrimary Care: final results of the OXCHECK study. Br Med J, 1995; 310: 1099-1104.
5 Legge A. Dear Pill. HSJ 1999; 109 (5564), 12-13.
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