With the smoking ban just days away, the government points to huge funding boosts for smoking cessation, but is the money hitting home? Daloni Carlisle reports
The adverts are everywhere. On television, billboards, public transport and in newspapers. The message is simple: the ban on smoking in public places is on its way. Quit now with the help of the NHS.
Free nicotine replacement therapy. Free Zyban. And a lovely health professional to hold your hand throughout.
The pressure group Action on Smoking and Health (ASH) estimates 689,000 people will quit smoking in the first year of the ban. Judging from previous figures, one in 20 of them will use NHS services. Which means 34,450 people could be heading for their local service in the next few weeks.
It has already begun. Liverpool primary care trust, one of the acknowledged leaders in stop-smoking services, has seen referrals double in parts of its patch compared with this time last year.
Elsewhere, though, there are serious doubts the NHS will cope with this predicted surge in activity. Some PCTs slashed their smoking cessation budgets in 2005-06 and there is no evidence of them being increased in 2007-08.
Concerns about the cuts come from a wide range of groups, including the public health community, the anti-smoking lobby and the Conservative Party.
It was the Conservatives who revealed in March the extent of cuts to NHS stop-smoking services, claiming that 56 of the 115 PCTs they surveyed had cut their budget in 2005-06.
Shadow health secretary Andrew Lansley called this 'an outrageous example of Labour's mismanagement and lack of concern for public health'.
'What is the point of anti-smoking campaigns if they can't be followed up?' he asked.
The Department of Health responded with details of the barrage of initiatives it has launched since the 1998 white paper Smoking Kills. 'There have been huge strides in tobacco control in this country, with advertising banned, stark warnings on packs, extensive support to help smokers quit and hard-hitting media campaigns,' says a spokesperson. July's ban is just the latest.
The money has held up, the spokesperson adds. 'This year£56m was allocated to the NHS for smoking cessation services - this is up from£51m last year.'
Stop-smoking services have been effective in helping people quit, says the DoH. Between April 2005 and March 2006, nearly 330,000 people had not smoked at the four-week follow-up used as a benchmark for stop-smoking services. 'We have already exceeded our three-year target to help 800,000 people quit by 2005-06, and still more and more people are successfully kicking the habit,' the spokesperson says.
Giving up on the NHS
Other evidence seems to be on Lansley's side, however. The Information Centre for health and social care's latest figures show that the numbers of people quitting smoking through NHS services is falling, down from 208,878 between April and December 2005 to 188,162 in the same period in 2006.
ASH director Deborah Arnott puts this down to funding. At a central level, she agrees government spending has held up. 'The problem is how that got translated at local level.'
UK Public Health Association chair Professor David Hunter says he does not see the figures looking up any time soon. 'There is a concern that there will be a rush of demand that NHS stop-smoking services will not be able to meet,' he says.
He blames not just the lack of resources but also the PCT reorganisation of 2006. In some regions, the appointment of PCT directors of public health is only just complete and recruitment of second- and third-tier managers - including those who manage stop-smoking services - is still under way.
Dr Hunter says: 'It has taken longer than any of us foresaw. People are still rudderless.'
Out in the regions, the DoH has funded 10 tobacco policy managers to support PCTs and local authorities as they implement the ban on smoking in public places.
London region manager Andrew Hayes says: 'Most of the London PCTs have been struggling with money and some of them have been cutting back services. Some of the community-based pharmacy services have been restricted or dropped. It is regrettable.'
For example, Brent Teaching PCT withdrew£200,000 from this year's funding for pharmacy-based stop-smoking services in April. With£25m savings to make this year, the PCT claimed it had no choice but to stop paying pharmacists£15 for each person they saw and a further£30 for everyone who had not smoked at four weeks.
In a statement, the PCT said: 'While reducing any service is regrettable, tough decisions regarding bringing the PCT back into financial balance have to be made. We have explained this to all our level-two [pharmacy] advisers in the community and asked for their co-operation on this matter.'
In other words, they have asked pharmacists to carry on doing it for free. The answer so far has been no.
Liverpool PCT, by contrast, has not cut back services. Like many, it has looked to other funding such as the Neighbourhood Renewal Fund or agreements with local authorities. The PCT is a member of Smokefree Liverpool, which also includes businesses and voluntary groups.
Sandra Davies is head of public health delivery. 'Our PCT is looking at every possibility for increasing support for the stop-smoking service,' she says. 'We have already seen referral rates rising and we know that many people are setting 1 July as their quit date. We do not want to be in a position where we have to put people on a waiting list.'
There is another question to answer, though. Does it really matter if NHS stop-smoking services are operating a skeleton service if only one in 20 quitters uses them?
Absolutely, says Association of Directors of Public Health president Tim Crayford. NHS stop-smoking services are free - and smoking is a huge health inequalities issue. 'If we are serious about health inequalities, we need to make it as easy as possible for people to access services,' he says.
There is also the issue of evidence-based practice. NHS stop-smoking services are informed by National Institute for Health and Clinical Excellence guidance, which is based on the best available evidence.
'That may or may not be true of someone who sticks a sign up saying they are a hypnotherapist,' Dr Crayford points out.
Questions have also been raised about just how effective NHS stop-smoking services really are and how open to abuse they might be. Stories abound of unscrupulous advisers making up figures and of service users selling their free NHS patches.
Dr Crayford says PCTs are audited to ensure data is good. 'The problem for the NHS is less the quality of data and more whether we are measuring the right thing,' he says.
Current PCT targets are based on reducing smoking rates in the manual working groups and are measured by success at four weeks. Does this really measure long-term quitting?
'What really counts is stopping for a year,' says Dr Crayford. 'We do not measure that because it is not quick enough and you lose too many people to follow up. The DoH should be looking at one-year quit rates.'
Ms Davies in Liverpool agrees. 'I think the four-week quit is useful in showing we can deliver something quickly,' she says. 'But we would like to measure longer term.'
NHS stop-smoking services also matter because of their increasingly wide remit, particularly in the workplace. This stems partly from the legislation, partly from the emphasis on targeting manual workers, and will be driven further with forthcoming NICE guidance on smoking, health and the workplace.
While some have been very successful (see 'PCT innovation', below), others have encountered real difficulties.
Mr Hayes relates the experience of a London PCT that worked with two large local employers. 'One was initially very keen to set up stop-smoking services in the workplace but pulled back when they realised they would have to pay,' he says.
'The other was a transport company where workers were on a shift pattern. Getting a group together so the same people were attending together was impossible within the service capacity.'
It is likely to be a mixed pattern, but at least there should be some solid data to work on in coming months. Each of the regions will conduct some informal evaluation. More substantially, the London Health Observatory (which leads on tobacco for all English public health observatories) is poised to develop a monitoring system. Details were being finalised at the time of writing but it is likely to include cessation data as well as the impact on other NHS services.
'We are interested in looking at premature death and ill-health and whether we can unpick some of the elements of that,' says LHO director Dr Bobbi Jacobson.
Mr Hayes, meanwhile, would like to see smoking cessation begin to make an impact on commissioning.
'I would love to see PCTs making sure more staff are trained in brief interventions - and that is across the board. In particular, we are not taking advantage of the opportunities to support people before they become inpatients.'
Generally known as 'stop before the op' campaigns, these aim to help people quit before elective surgery. Just a week or so smoke-free makes a big difference to recovery times.
'If PCTs commissioned services from acute trusts that built in a requirement that all smokers would be given brief intervention advice and referred to stop-smoking services on discharge, now that would make a difference.'
Primary care trusts have been engaged in a wide range of innovative work in the run-up to the ban on smoking in public places, supporting businesses and working with hard-to-reach groups. Some examples:
- Smokers attending cessation classes in Southampton receive free gym membership.
- Buckinghamshire now offers a desktop cessation service for shift-workers who find it difficult to get to the regular session. This provides more support at a venue and a pace suitable for each person.
- Liverpool has reached out to young men with a 'blow and go' service where they can access carbon monoxide monitoring and get quick access to nicotine replacement therapy.
- In London, PCTs have tackled complex issues such as shisha pipes ('hookahs') and getting homeless hostels on board with the ban.
How many people smoke?
- 40 per cent of adults smoked in 1978
- 27 per cent of adults smoked in 1998
- 24 per cent of adults smoked in 2005
(ONS, General Household Survey, Nov 2006)