Celebrating the NHS's stop smoking champions

To celebrate these successes, the Department of Health and Health Service Journal ran a competition to find the “local heroes” of the last decade - the healthcare professional referrers and advisers who have worked together to develop best practice systems and make a real impact on reducing smoking rates in their community.

The winning champion referrers and their champion advisers were announced at a prestigious 10 year anniversary reception in the House of Commons, attended by health minister Gillian Merron.

Congratulations go to:

• Louise Ross, STOP! smoking service, Leicester
• Jo Woodvine, Bexley NHS stop smoking services
• Gary Bickerstaffe, NHS Bolton and Royal Bolton Hospital
• Jane Roberts, Blackpool NHS stop smoking services
• Cathy Baldwin, East Sussex stop smoking services
• Sue Hewitt, Northamptonshire Healthcare Foundation Trust
• Kostakis Christodoulou, Horizon Trust and East Hertfordshire Trust
• Penny Morioka, Lewisham NHS stop smoking service
• Simon Kelly, consultant ophthalmic surgeon, Bolton
• Anna Fairhurst, Brighton and Hove NHS stop smoking services

Here we look at the winning entries:

Cutting smoking levels is a high priority for NHS Leicester City where smoking-related illnesses cost the NHS around £18m a year. Staff in some clinical areas estimate that around 70 per cent of their patients smoke.

As a result, STOP! Leicester appointed an experienced specialist adviser for secondary care to work across all its hospital sites.

To prioritise the adviser’s work an exercise was carried out to analyse where knowledge of the NHS stop smoking services was lowest. Following this, more than 300 staff were trained to give brief advice to smokers and a pilot programme was developed to issue nicotine replacement therapy to inpatients in cardiac and respiratory wards.  Next steps for the programme include the introduction of fast track electronic referrals and an IT system will be added by the end of 2009.

Due to the success of the initiative, a commissioning for quality and innovation scheme has also been developed. University Hospitals of Leicester will recruit a smoking cessation specialist nurse to work with the STOP! team. As a whole, the initiative demonstrates exemplary joint working between primary and secondary care and was shortlisted for the UHL 2009 Awards.

The results

• Referrals from the University Hospitals of Leicester to STOP! doubled from 60 per quarter to 120 per quarter in less than six months.
• All patients receiving smoking cessation advice from staff while in hospital now receive a follow up appointment with their local smoking cessation service on discharge.

Bexley has a free, effective and successful NHS stop smoking service. However, many smokers are unaware that they are up to four times more likely to quit by accessing support from their GP based community stop smoking adviser rather than by trying to quit on their own. Bexley relies heavily on its GP based community stop smoking advisers to deliver its Department of Health smoking cessation targets and, as a result, maintaining their ongoing commitment is essential.

GP surgeries were set individual smoking cessation targets for 2008-09. Progress against these targets was monitored and communicated to all via quarterly league tables. In addition, these league tables were discussed at practice based commissioning meetings, ensuring all stakeholders were aware of their achievements.

To provide additional support for GPs, Bexley stop smoking services offers evening smoking cessation surgeries, staffed by trained community professionals. To drum up attendance at these surgeries, postcards were sent to all registered smokers on GP lists inviting them to attend. Following the postcards phone calls were made offering appointments to interested patients.

Bexley NHS stop smoking services also offers training to GPs on how to deliver motivational advice and sell the benefits of the full range of smoking cessation medications.

The results

• All GP surgeries in Bexley now offer one to one support to any smoker who wants to quit.
• All surgeries are fully aware and committed to delivering their quota towards the 2009-10 smoking cessation target.

Bolton NHS stop smoking service decided to work with their local hospital to develop a proactive, effective and efficient secondary care system of support for hospital patients who want to quit.

To kick start the project healthcare staff from Royal Bolton Hospital and the Bolton NHS stop smoking service worked together to develop proactive assessment and referral forms, training packages and a system of seamless referral and follow up.

This efficient system of treatment and support is now used by healthcare staff from both the primary and secondary care settings to help patients. In effect, it has become sustainable shared practice, with many staff involved rather than just a few. While the system presently operates in a few areas of the hospital, a two year pilot scheme is being rolled out across all departments.

The results

• Since initiating the programme, the hospital has referred more than 5,000 people directly to the local NHS stop smoking service.
• The programme has helped more than 1,000 hospital inpatients to access smoking cessation. The medication costs stand at approximately £22,000, a figure that is considered to be highly cost effective.
• Seen as a benchmark for trusts around the country, the hospital is regularly contacted by others seeking a template to develop their own practices. The hospital freely shares its training packages and examples of the various forms and protocols that it has developed.

Blackpool’s smoking prevalence rates 303rd out of 324 local authorities. The smoking in pregnancy rate is currently 39 per cent. Estimates show that around 36,000 of the Blackpool population over the age of 16 smoke. Since 2002 a specialist service has served those who want to self-refer and quit. On average, the service attracted only 10 per cent of the smoking population.

To improve the service and tackle Blackpool’s smoking prevalence, a local enhanced service was set up in general practices to make high-efficacy treatments easier to access, particularly for those with health and social inequalities.

To increase reach, choice and access, it was agreed to extend the service into dental practices where smokers could be recruited at routine appointments. Blackpool has the second worst adult dental health in Cumbria and Lancashire and extensive treatment provision, making dental teams ideally placed to become actively involved in smoking cessation.

An event for dental teams was held in July 2008 to sell the new service and clarify what would be involved. The barriers for dentists were discussed as well as how the referral service might work. Following the event four practices agreed to pilot the scheme and another six expressed interest.

Dental team members (dentists, hygienists, and dental nurses) attended mandatory training to acquire the necessary competencies to be accredited to deliver the service. This was backed up with a self-learning toolkit containing all the relevant information including a copy of the Manual of Smoking Cessation, a carbon monoxide monitor and an NRT sample kit. The agents were trained to provide NRT via the voucher scheme. Ten potential agents were trained and took the lead in developing a system with their practice. Additional training was provided on-site according to need.

The results

•  After only three months 120 smokers had set a quit date and 27 quitters had reached the four week quit date

In order to reach smokers in the workplace, East Sussex NHS stop smoking services began contacting businesses in the local area with the aim of setting up smoking cessation workplace clinics. In addition to these calls 10 companies a month were selected to receive a tobacco cessation pack, outlining the NHS stop smoking services provided in East Sussex along with a reply slip and self addressed envelope.

Following every communication, a database of business interventions was collated logging the details of every company that had been targeted and/or participated. Once contact has been established East Sussex NHS stop smoking services works to develop this relationship through regular calls and seasonal greetings cards.

To continue its reach among local businesses and employees East Sussex stop smoking services will soon be taking the primary care trust stop smoking van to local industrial estates to run a weekly clinic in the van for manual workers, who may otherwise not be able to access the service.

The results

• From no activity with local employers the service has established 17 workplace clinics achieving a 40 per cent success rate.

Finding the resource to support people with learning disabilities who expressed an interest in stopping smoking was often found to be a challenge for local community nurses in Northamptonshire. In addition, when NHS premises became smoke free in 2006, adequate support was not always in place to help smokers who lived in NHS residential homes, many of whom had lived in institutions for many years.

In response to these challenges a smoking cessation interest group was formed to support people with learning disabilities. The group, assembled by the local NHS stop smoking adviser from the Northamptonshire Teaching Primary Care Trust, consisted of nursing staff from across the county’s residential and community learning disability services, all of whom completed intermediate smoking adviser training.

Following their training the group conducted a literature search that revealed a lack of accessible information for people with learning disabilities. The group took on the challenge of providing resources specially adapted for our client group. A resource pack was developed, based on a recognised five-stage health promotion model. People with learning disabilities were involved in developing an easy to read list of the benefits of giving up smoking and were consulted over developing symbols, flash cards and relaxation tapes. Easy read care plans, management plans, assessment sheets, monitoring sheets and evaluation sheets were also included. In addition to these materials Northamptonshire Healthcare Trust invested in carbon monoxide monitors to be included in the packs.

The results

• To date, 22 clients with learning disabilities have been supported to stop smoking and eight have stayed smoke free.
• The pack has been replicated so there are two packs available across the county.
• Smokers in trust residential homes are now using easy read management plans to manage their smoking and protect non-smokers from second hand smoke.
• The resource pack won the trust’s ‘Simply Improving Services’ award in 2007 and an East Midlands health and social care award in 2008.
• Finally, an unexpected benefit has been the interest it has generated among carers in trying to quit smoking themselves.

There are few specialist resources available to help people with learning difficulties and those unable to read or write. In these instances specialist stop smoking advisers need additional visual resources.

To tackle this issue Hertfordshire Health Promotion, Horizon Trust and East Hertfordshire Trust worked together to develop a smoking awareness pack for people with learning disabilities.

The pack was developed in partnership with ASH, the Health Development Agency, QUIT, Royal London Hospital Medical College, St George’s Hospital Medical School, Dr Peter Hajek, Ann Lee, and Professor Robert West. It has been distributed nationally to support NHS stop smoking services.

The pack describes the effects of smoking on health and helps identify where the smoker is in the process of change and if the smoker is ready to stop. It is a useful tool for providing information on ill health related to smoking, nicotine replacement products and withdrawal symptoms. It is predominantly visual and is designed for use by stop smoking facilitators working with young people and adults who have difficulty with written materials.

The pack is particularly effective in engaging with hard to reach groups from diverse communities, communicating to people in a simple language. Cartoons are used to outline key health promotion messages and provide the basis for discussion with people who have difficulty with written materials. The pack has specifically helped those who do not have English as their first language.

The results

• The pack has been used as a model by numerous stop smoking services nationally.
• It was presented in Finland as part of an international conference on effective communication and at the international Health Promoting Hospital conference as good practice.
• It won the Health and Social Care Awards 2008.
• One trust has used the pack to help 13 people with learning disabilities to access the stop smoking programme. Of these 13, four have stopped smoking for three months or longer.

The North Downham training project in Lewisham was set up as an access to work project which also provided stop smoking support. The project was adapted to suit the needs of local people, taking a holistic approach towards clients’ needs. It has the freedom to offer more time over a longer period than some of the NHS stop smoking programmes.

The project targeted isolated groups who did not regularly access stop smoking services. A support group and drop-in service was established at the Downham 999 Club as many of the people who attend have complex mental and physical health problems and may be dependent on other substances or homeless. In this way the the project was able to offer advice along with free tea and toast to a diverse audience. Sessions at the 999 Club are run weekly to provide continuing support for those who may relapse.

Following the success of the 999 Club, the project was commissioned by Lewisham stop smoking service to set up a drop in at Downham where support is not only given to smokers, but to newly qualified stop smoking advisers. The drop-in service started out as a weekly three hour session, but as demand increased another weekly session was scheduled. While the initial target group was people in employment, clients are now referred by GPs as well.

The results

• More than 100 people have come to these sessions for advice and information. Forty of them have now quit.

Mr Kelly, an ophthalmic surgeon in Bolton, has been drawing attention to the link between smoking and eye disease throughout his career. He has continually advocated changes in government policies and campaigned for professional practices to routinely offer smoking cessation advice/support in eye care settings.

An inter-professional team, the eyes and tobacco study group was set up to develop a programme of education and research with the aim of targeting policy makers, healthcare professionals, the public and patients. The team reviewed evidence about the causal link between smoking and eye disease, researched current awareness of the link and how eye care health professionals treat smokers. As a result of this research, the team produced health education materials and campaigned for policy changes.

Teaching programmes were also developed with ophthalmologists and optometrists nationally to improve smoking cessation services in hospital and community based eye care settings.

Following this, Mr Kelly undertook research with hospital OPD patients and teenagers in the community assessing the extent to which blindness is a compelling public health message for smoking cessation.

As changes to tobacco product warnings require EU agreement, the team successfully drew European parliamentarians’ attention to the link between smoking and eye health.

The results

• The UK’s chief medical officer and the European Commission have made a commitment, in principle, to include warning labels related to blindness on cigarette packets.
• The ocular hazards of smoking were included in the recent 2007 EU green paper Towards a Smoke Free Europe.
• 1,000 eye health leaflets, produced with the charity North West Action on Smoking and Health, have been distributed to NHS clinics.

In 1995 Anna, a respiratory and cardiac nurse, developed a smoking cessation clinic at Royal Sussex County Hospital. Following the success of her work, ongoing funding was provided by Health of the Nation and Our Healthier Nations, allowing the project to develop into a fully co-ordinated service.

In 2003 Anna’s track record and quit evidence demonstrated to local NHS public health directors that smoking cessation clinics were vital to tackling health issues and South Downs Health Trust was commissioned to run the NHS stop smoking service. Anna was appointed service manager looking after a specialist team and delivering training to GPs and pharmacists.

Training is a cornerstone of what makes this service such a success and Anna has trained more than 500 health professionals to level one and two smoking cessation. Having such a large number of qualified trainers ensures patients across the city have access to help in a variety of accessible locations and convenient times. These trained professionals also increase the number of referrals to the specialist team who can offer more time and expertise for quitters. 

Bringing onboard medical directors and respiratory consultants gave the service clinical credibility and a real point of success was running the service as an outpatient clinic like any other such as asthma or diabetes. Having GPs committed to the clinic was vital and served as a solid foundation for receiving and quickly increasing referrals. 

Anna’s dedication, leadership and relationship building have played a vital role in making the service a success. Practice nurse Angie Waters said: “Anna runs excellent training and gives us a lot of support.  Her service is well organised and I always get directly through to her team which makes it so easy, especially when I refer a patient who needs specialist support like an under 16 smoker.” 

The results

• Anna has trained more than 500 health professionals to level one and two smoking cessation. This equates to 85 per cent of Brighton and Hove GPs and practice staff and over 50 per cent of the region’s pharmacy staff. 
• In 2008 there were 2,882 referrals to the specialist NHS stop smoking services, a 371 per cent increase from 2004.
• In 2008 2,013 successfully made it to their four week quit date.