Prevention and Promotion Technical Team
Smoking Cessation
Authors: Mererid Bowley, Locum Consultant in Public Health
Margaret Munkley, Principal Public Health Specialist
Date: 15 September 2010 / Version: 1
Publication/ Distribution:
· Prevention and Promotion Programme Board
· Public Health Wales (Intranet)
Purpose and Summary of Document:
This paper has been prepared to support the work of the Prevention and Promotion Programme Board in identifying cost effective public health interventions to support NHS Wales in achieving financial balance through the development of increased efficiency and sustainable services.
This paper outlines the case for the potential of smoking cessation interventions to realise savings as one of the high impact areas for the NHS Wales Five Year Plan. Information on the health and economic impact of smoking is outlined along with the potential health and cost benefits that may arise in consistently and systematically implementing smoking cessation interventions within the NHS in Wales.
The following smoking cessation interventions are considered within this report:
§ pre-operative smoking cessation
§ support to NHS employees who smoke, to quit
§ support to pregnant women who smoke
§ brief intervention to smokers delivered by GPs.
Given the tight timeframe within which this piece of work was undertaken, further work is recommended to develop the potential of the interventions, including economic assessment and modelling of health gains and cost savings by a Health Economist.
1 Introduction
This paper has been prepared to support the work of the Prevention and Promotion Programme Board in identifying cost effective public health interventions to support NHS Wales in achieving financial balance through the development of increased efficiency and sustainable services.
This paper outlines the case for the potential of smoking cessation interventions to realise savings as one of the potential high impact areas for the NHS Wales Five Year Plan. Information on the health and economic impact of smoking is outlined along with the potential health and cost benefits that may arise in consistently and systematically implementing smoking cessation interventions within the NHS in Wales.
Given the tight timeframe within which this piece of work was undertaken, further work is recommended to develop the potential of the interventions, including economic assessment and modelling of health gains and cost savings by a Health Economist.
The following smoking cessation interventions are considered within this report:
§ pre-operative smoking cessation
§ support to NHS employees who smoke, to quit
§ support to pregnant women who smoke
§ brief intervention to smokers delivered by GPs.
2 Public Health Impact of Smoking
2.1 Smoking and health
Smoking is the largest single cause of avoidable ill health and early death in Wales. Nearly a quarter (24%) of the adult population smoke1. Smoking is associated with more than 50 different diseases and disorders and a major cause of health inequalities; it accounts for more than half of the difference in risk of premature deaths between social classes2.
In Wales, smoking causes nearly one in five of all deaths, an estimated 5,600 deaths each year; this equates to 15 deaths per day3. In the United Kingdom, in 2000, smoking caused4:
§ 29% of all cancer deaths
§ 86% of lung cancer deaths
§ 13% of cardiovascular deaths
§ 30% of respiratory deaths
§ 19% of all total deaths.
2.2 Smoking and surgical health
Smoking substantially increases the risk of poor outcomes after surgery. There is strong evidence5 that after surgery, compared with ex-smokers and non-smokers, smokers are more likely to:
§ have lung, heart and infectious complications
§ have reduced bone fusion after fracture and impaired wound healing
§ be admitted to an intensive care unit
§ have longer length of stay in hospital
§ have an increased risk of dying in hospital.
2.3 Smoking and maternal health
In 2005, an estimated 22% of mothers smoked throughout their pregnancy. The risks of smoking in pregnancy include substantially higher risk of miscarriage, and complications in pregnancy and labour. Smoking in pregnancy increases risk of preterm and low birth weight babies. Babies are born on average 200-250g lighter, and the more cigarettes smoked the greater the reduction in birth weight. Smoking during pregnancy increases the risk of infant mortality by an estimated 40%. Low birth weight has also been associated with coronary heart disease, type 2 diabetes, and being overweight in adulthood. Babies born to mothers who smoke are more likely to develop middle ear infections, respiratory infections and asthma6.
Passive smoking during pregnancy can reduce foetal growth and increase the risk of preterm birth. Second hand smoke can increase the severity of illness in those already affected6.
3 NHS Service Impact
3.1 Cost of smoking to the NHS in Wales
There is a significant burden of illness due to smoking which has major costs for the NHS in Wales. A recent study undertaken by Swansea University7, reported that treating smoking related diseases cost the NHS in Wales:
§ 7% of total healthcare expenditure in 2007/08
§ equivalent to £129 per head of population
§ an estimated £386 million annually; more than £7 million each week and over £1 million a day.
Secondary care accounted for 67% of the total cost and primary care 33%. In terms of breakdown, smoking accounted overall for an estimated:
§ 22% (> £235 million) of adult hospital admission costs
§ 6% (> £21 million) of outpatients costs
§ 13% (> £43 million) of GP consultations
§ 12% (> £6 million) of practice nurse consultation costs
§ 14% (>79 million) of prescribing costs7.
A technical report by the London Health Observatory8, commissioned by the Welsh Assembly Government, calculated the smoking attributable admissions, bed days and costs for the NHS in Wales in 2005/06. Smoking was calculated as the cause of an estimated:
§ 28,000 hospital admissions
§ 722 hospital beds utilised as a result of smoking related illness per day
§ cost to NHS Trusts in terms of bed days[a] of nearly £87 million per annum.
A recent study by the Public Health Research Consortium9 estimates the economic costs[b] to the NHS, in the UK, of smoking in pregnancy for pregnant women and infants during their first year following birth. This study was confined to NHS costs and did not consider the longer term costs to health and health related quality of life.
§ The cost of smoking, to the NHS in the UK, during pregnancy was estimated to be in the range of £8 million - £64 million per year based on different costing methodologies. This relates to an increased risk of spontaneous abortion, ectopic pregnancy, placenta previa, abruptio placenta, preterm rupture of membranes, and increased risk of pre-eclampsia9.
§ The cost of smoking in pregnancy for infants during the first year following birth was estimated to range between £12 million and £23.5 million per year, and relates to an increased risk of pre-term delivery, low birth weight, Sudden Infant Death Syndrome, perinatal mortality, asthma, otitis media, and upper and lower respiratory infections. The care of low birth weight and preterm infants accounted for most of the costs9.
If the number of birthsc is used as a crude proxy, the proportion of pregnancies in Wales is 4.4% of UK pregnancies, the cost to the NHS of smoking during pregnancy in Wales can be calculated at between an estimated £352,000 and £2,816,000 per year.
Similarly, if the proportion of births in Wales is 4.4% of UK births[c], then a crude estimated total cost to the NHS of smoking during pregnancy for infants (0-12 months) in Wales can be calculated at between an estimated £528,000 and £1,034,000.
Date: 23 September 2010 / Version: 1 / Page: 1 of 25Public Health Wales / Smoking Cessation
3.2 Cost of smoking to the NHS workforce
A review of the health and well-being of the NHS workforce found that among NHS employees, the likelihood of sickness absence is a third higher for smokers compared to non-smokers; and smokers are more likely to be absent due to ill health, and for longer than a non smoker10.
A health economic review11, conducted to inform the development of National Institute for Health and Clinical Excellence guidelines Workplace interventions to promote smoking cessation12, reported that productivity losses due to illness and increased absences from work amounted to 33 hours per smoking employee per year. This is 33 hours more that a non-smoking employee and does not include lost productivity due to smoking breaks.
The NHS could also incur additional costs for agency/locum cover for sickness absences. The rates for cover can range from around £10 to more that £104 per hour depending up on grade and speciality.
3.3 Cost of smoking to the economy
It is estimated that each year 34 million working days are lost in England and Wales through sickness absence caused by smoking related illnesses13. Smoking also costs the wider UK economy an estimated £2.5 billion per annum for sick leave and lost productivity14.
4 Interventions
Individual, group and telephone behavioural support are effective smoking cessation interventions and their effectiveness increases with treatment intensity.
4.1 Pre operative smoking cessation
Target population - Patients living in Wales awaiting surgery who are smokers
Intervention - Brief intervention delivered by all healthcare staff and referral onwards to Stop Smoking Wales for intensive behavioural support
A recent updated Cochrane Systematic Review15 reported that preoperative smoking cessation interventions can reduce the risk of postoperative complications.
Brief intervention for smoking cessation can be summarised as a method of discussing smoking and quitting in a positive, non-confrontational way to encourage smokers to think about giving up and enable them to access specialist support when they are ready. Intervention typically takes no more than 5 minutes.
Brief Intervention for smoking cessation involves health professionals:
§ Asking about current smoking status and documenting
§ Advising patients on health effects of smoking and benefits of stopping
§ Acting: documenting smoking status in patient notes; providing self help material; and referring smokers who want to quit for specialist smoking cessation services, such as Stop Smoking Wales.
Pre operative smoking cessation delivered 4-8 weeks before surgery has the greatest impact on reducing postoperative morbidity. The intensive smoking cessation behavioural support programme would be delivered to smokers, awaiting elective surgery, who want to stop smoking. Smokers participating in the behavioural support programme would receive:
§ support for 1 hour a week for 6-weeks (in groups)
§ appropriate behavioural support strategies, support and help to set a quit date and throughout the quitting process
§ standardised information on the range of pharmacological aids available, which will include brief information on the use of products and on contraindications
§ support to understand which pharmacological aids to quitting would be most appropriate for them in relation to previous cessation attempts and information on their smoking behaviour
§ supporting information to give to prescribers confirming their motivation to quit, information on their level of nicotine dependence using a validated tool and other relevant information on previous cessation attempts.
4.2 Support to NHS staff who smoke to quit
Target population - NHS Health Board employees who smoke and want to quit smoking
- All Health Board staff, patients and visitors to NHS premises and grounds
Intervention - Intensive behavioural support programme delivered over a period of 6-7 weeks
- Introduction and implementation of smoke-free
policies throughout NHS grounds (in addition to
enclosed premises)
The workplace has several advantages as a setting for promoting tobacco control as:
§ large numbers of people can be reached
§ there is the potential to provide peer group support
§ the no smoking working environment encourages people who smoke to quit.
The two interventions of support to staff and introducing a smoke free policy have been combined under one intervention as the introduction of a smoke free policy will promote a smoke free environment which can encourage staff to quit smoking.
Research has demonstrated that evidence-based smoking cessation services are a highly cost-effective way of helping smokers to stop smoking16; 17; 18.
There is good evidence from a Cochrane Systematic Review19 to support the delivery of smoking cessation behavioral support programmes in the workplace setting to help smokers motivated to stop smoking. There are also National Institute for Health and Clinical Excellence guidelines to support the delivery of smoking cessation support in the workplace12;18 .
There is also good evidence to support organisations to promote smoke free workplaces which contribute to decreasing smoking consumption during working hours20. Health Boards should act as exemplar employers by promoting smoke free environments to discourage smoking and to promote health and well being. Smoke free environments for Health Boards would mean introducing and implementing a smoke-free policy throughout NHS grounds (to cover all the premises), in addition to current enclosed buildings. NHS staff also have the opportunity to act as role models for promoting health and healthy behaviours. NHS staff smoking in uniforms in visible smoking areas on NHS premises sends a contradictory message regarding the public health risks and health outcomes of smoking.
4.3 Support for pregnant women who smoke to quit
Target population - Pregnant women who smoke
Intervention - Brief intervention delivered by all midwifery staff
at every opportunity, to include an assessment of exposure to tobacco smoke via a carbon monoxide breath test; opt out referral system to refer clients onwards to Stop Smoking Wales for intensive behavioural support programme. Training in brief intervention for all midwifery staff.
There is good evidence from a Cochrane Systematic Review to support interventions to promote smoking cessation in pregnancy21. There are also National Institute for Health and Clinical Excellence guidelines to inform smoking cessation interventions in pregnancy and following childbirth22. The evidence suggests that this client group would require intensive and ongoing support to stop smoking throughout pregnancy and postnatal from specialist NHS service.
Review level evidence suggests that pregnant women are more likely to reduce smoking consumption when accessing smoking cessation programmes which tailor the behavioural intervention method and address the concerns of pregnant women; this leads to a greater acceptance of intervention23. The National Institute for Health and Clinical Excellence guidelines recommends that all midwives should be trained to use brief intervention skills for smoking cessation to raise issue of smoking, and initiate referral to NHS smoking cessation services for intensive and ongoing support.