Could the death toll have been lowered by offering nicotine replacement therapy on the NHS earlier? Emma Baines looks through the policy history of smoking cessation

In 1996, 28 per cent of UK adults smoked. The decline of smoking had started to level out since the early 1980s and it looked as though the habit was here to stay. Cigarettes were responsible for 120,000 deaths a year through smoking-related illness at an estimated cost to the health service of£1.7bn each year.

When Labour came to power in 1997, a stated health policy goal was to tackle smoking. In 1998 the white paper Smoking Kills summarised the evidence in favour of a national stop smoking policy and set out a raft of measures aimed at reducing the damage done by the habit. The government pledged£100m over three years to fund specialist stop smoking services on the NHS. These were to be set up by health authorities and health boards in line with local needs, with a particular focus on deprived areas.

Professor Robert West, director of tobacco studies at the Cancer Research UK Health Behaviour Research Centre at University College London, helped develop the stop smoking framework that was incorporated into the white paper. He says the evidence in favour of offering smoking cessation on the health service was overwhelming, although nothing of the kind had ever been introduced on a national scale before.

"There was a strong sense that a case for smoking cessation services had already been made. It was just that it hadn't been acceptable on a political level. But when New Labour got in to power everything fell into place," he said.

First targets

The white paper also set the first smoking cessation targets for England: by 2010 the percentage of adults aged over 16 who smoke should be reduced to 26 per cent; the number of children smoking should be cut from 13 to 9 per cent; and the number of pregnant women smokers should be down to 15 per cent from 23 per cent. These targets were revised in the 2000 NHS Cancer Plan to the current targets of 21 per cent in the general adult population and 26 per cent for manual groups.

The stop smoking services were launched in 1999. Providing access to treatment and support to groups of quitters, or on a one-to-one basis, they proved to be more popular than expected. It was estimated that around 2 per cent of smokers, or around 200,000 people in England, would be interested in making use of the service, but demand was found to be much higher.

Data from the NHS information service for 2001-02 shows that 119,834 people accessing a stop smoking service in England had successfully given up at their four-week follow-up. By 2006-07 this figure had risen to 317,720, with more than 600,000 smokers accessing the service and setting a quit date.

A major part of the stop smoking strategy has been to widen access to treatments, including nicotine replacement therapy, bupropion and varenicline. Although it has been available in the UK on private prescription since the 1980s, nicotine replacement therapy was not available on NHS prescription until April 2001.

In the 1990s when it came up before the Borderline Substance Committee, a precursor to NICE, it was ruled that this should not be made available on the health service.

"I think this was a unique case where a medicine that was known to be effective and was licensed was not made available on the NHS," says Professor West.

Nicotine therapy

In addition, there were widespread fears that allowing nicotine replacement therapy on prescription would break the bank. These fears have not been realised since most people are happy to buy nicotine replacement therapy themselves rather than go to the bother of getting a prescription, and in 2004 there were around two million prescriptions for it in England, at a cost of£44m.

The stop smoking services were one component of a wider strategy. Other measures included banning advertising, increasing the price of cigarettes year on year and introducing bans on smoking in the workplace. Arguably the most successful of these initiatives was the smoking ban introduced in Scotland in March 2006 and then rolled out in England, Wales and Northern Ireland in 2007, which brought to an end to smoking in enclosed public spaces.

Before it was introduced in England, there was resistance to the notion of a total ban, particularly from the health secretary at the time, John Reid. "There was strong popular support for it, even among smokers, but John Reid and the hospitality industry put up a big fight and I don't think we would have got a comprehensive smoking ban that covered all bars and restaurants if John Reid had not been replaced by Patricia Hewitt," Professor West recalls.

The effect of the ban on smoking prevalence to date has been dramatic, with a 4 per cent drop in England over the first nine months and an increase of around 20 per cent in the number of smokers accessing NHS stop smoking services.

Professor West says: "The ban is having a huge effect on smoking. The drop in prevalence in the months following the introduction of the ban is the biggest decrease this country has ever seen."

Influence of culture

The challenge facing smoking cessation services in Scotland has been greater than elsewhere in the UK. In 1995 the prevalence of smoking in adults was 35 per cent and in deprived areas was much higher.

Liz Grant, a public health pharmacist in NHS Greater Glasgow and Clyde, who pioneered a pharmacy-based smoking cessation service that has now been rolled out across all pharmacies in Glasgow and Clyde said: "The smoking rate is higher overall in Scotland, and there are pockets of the population in Glasgow where the smoking rate in the adult population is as high as 70 per cent. It's embedded in the culture."

By 2006 the stop-smoking services in Scotland had achieved remarkable results, already overshooting the 2010 adult smoking prevalence target of 29 per cent that was set by the Scottish Executive in 2004. Already in 2004, the percentage of adults aged over 16 who smoked was down to 26.5 per cent.

Ms Grant says the ban on smoking in public places was a huge success in Scotland, resulting in a 50 per cent increase in the number of patients accessing stop smoking services in the three months leading up to and after the ban: "We succeeded in helping a lot of people to quit at that time. It's been really good and even most smokers think it has been a positive thing."

Additional spending

Earlier this year, the Scottish government published an action plan that allocated an additional£9m over the next three years to smoking prevention and cessation services. It set a revised 2010 adult smoking prevalence target of 22 per cent.

It also introduced the Health Efficiency Access and Treatment performance targets that all local health boards in Scotland will have to meet. Under these, over the next three years 8 per cent of smokers have to have accessed smoking cessation services, and 30 per cent of them must be smoke-free at four weeks.

"It's the first time that we've had to deliver on something that is measurable," Ms Grant says. "It's now essential that we are only taking people who are serious about quitting, otherwise the outcome data will be very poor."

Whether or not the HEAT targets will be met, the NHS stop-smoking services in Scotland have already achieved a great deal.

"I don't think you'll ever have a completely smoke-free Scotland because there will always be pockets of hard-to-reach people," Ms Grant continues, "but I'd say that around 90 per cent of smokers know they should quit and want to quit. They're just finding it difficult."

The cumulative effect of the strategies to curb smoking in the UK has been very successful, and the chances of meeting the adult 2010 smoking prevalence targets look good, with prevalence in England already down to 22 per cent in 2006. In some places, the targets have been significantly overshot, with smoking prevalence in London, for instance, currently at 15 per cent despite many areas of deprivation in the capital.

Looking to the future, Professor West says that more ambitious targets will have to be set: "The UK has the capacity with everything it is doing to really move the goal posts quite a bit. At the moment we're aiming for smoking prevalence in the region of 20 per cent. I think that 15 per cent is a very realistic goal within 10 years. London is already there, despite areas of significant deprivation, and if London can do it, so can the rest of the country."

But he is amazed at how far the UK has already come in tackling smoking. "In the early 1980s none of us ever thought that we'd see the day when there would be a national stop smoking service, or that nicotine replacement therapy and these other smoking cessation treatments would be available on prescription. It's all been very surprising." l


NICE smoking cessation services guideline

Smokefree England

Department of Health tobacco page

Tobacco Information Scotland

South London and Maudsley NHS trust smoking cessation clinic

Cochrane Reviews