Hiding in plain sight sight plain in Hiding Treating tobacco dependency the NHS in tobacco Treating Hiding in plain sight Treating tobacco dependency in the NHS A report by the Tobacco Advisory Group of the Royal College of Physicians Royal College of Physicians 11 St Andrews Place Regent’s Park London NW1 4LE www.rcplondon.ac.uk June 2018 Hiding in plain sight Treating tobacco dependency in the NHS A report by the Tobacco Advisory Group of the Royal College of Physicians June 2018 Title page.indd 1 07/06/2018 15:12 Acknowledgments The Tobacco Advisory Group acknowledges the help of the UK Centre for Tobacco and Alcohol Studies (www.ukctas.net), which is funded by the UK Clinical Research Collaboration, for supporting much of the original research and literature reviews contained in this report; and thanks Priscilla Sharland for copyediting and Hannah Cole and the team in the Royal College of Physicians Publications Department for their work in producing the report. The Royal College of Physicians The Royal College of Physicians (RCP) plays a leading role in the delivery of high-quality patient care by setting standards of medical practice and promoting clinical excellence. The RCP provides physicians in over 30 medical specialties with education, training and support throughout their careers. As an independent charity representing 34,000 fellows and members worldwide, the RCP advises and works with government, patients, allied healthcare professionals and the public to improve health and healthcare. Citation for this document Royal College of Physicians. Hiding in plain sight: treating tobacco dependency in the NHS. London: RCP, 2018. Copyright All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher. Copyright © Royal College of Physicians 2018 ISBN 978-1-86016-731-7 eISBN 978-1-86016-732-4 Royal College of Physicians 11 St Andrews Place Regent’s Park London NW1 4LE www.rcplondon.ac.uk Registered Charity No 210508 Typeset by Cambrian Typesetters, Camberley, Surrey Printed and bound in Great Britain by The Lavenham Press, Suffolk Contents Members of the Tobacco Advisory Group vii Contributors viii Foreword xii 1 Introduction 1 1.1 Tobacco smoking and health 1 1.2 Policies to prevent smoking in the UK 1 1.3 Services to help people to quit smoking 4 1.4 Objectives of this report 6 1.5 Summary 6 2 Associations between smoking and disease 9 2.1 Introduction 9 2.2 Smoking, mortality and life expectancy 9 2.3 Smoking and the risks of specific diseases and disorders 10 2.4 UK national cohort analysis of morbidity and mortality from smoking 31 2.5 Effects of smoking cessation after diagnosis on disease natural history or other outcomes 39 2.6 Summary 43 3 The financial cost of smoking to NHS secondary care 53 3.1 Introduction 53 3.2 Secondary care costs in the general adult population 54 3.3 Effects of maternal smoking during pregnancy 65 3.4 Passive smoking effects on child health 68 3.5 The cost of surgical complications due to smoking 70 3.6 Secondary care costs from smoking among people with mental disorders 72 3.7 Costs arising from smoking by NHS staff 82 3.8 Summary 93 © Royal College of Physicians 2018 iii Treating tobacco dependency in the NHS 4 Providing stop smoking services and treatment for tobacco dependency in the NHS 98 4.1 Introduction 98 4.2 Treatments for tobacco dependence and their effectiveness 98 4.3 Harm reduction 104 4.4 Smoking reduction 104 4.5 Novel approaches 105 4.6 Approaches and cautions with treatment of tobacco dependency in patient subgroups 107 4.7 Treating smokers who use the NHS 110 4.8 Cost-effectiveness of smoking cessation in relation to therapies used routinely to treat diseases caused by smoking 117 4.9 Summary 117 5 Commissioning stop smoking interventions in the NHS 126 5.1 Introduction 126 5.2 Expenditure on the NHS, public health and stop smoking services 126 5.3 Commissioning the health service and public health in England 127 5.4 Local government and stop smoking services in England 128 5.5 Commissioning in the NHS and stop smoking treatment in England 134 5.6 Integrating health and social care in England 139 5.7 Commissioning stop smoking services in the devolved nations 139 5.8 Approaches to stop smoking service model design and provision in other countries 143 5.9 A proposed new model for treating tobacco dependence in the NHS 144 5.10 Summary 145 6 Using data to drive improvement in treating tobacco dependence 150 6.1 Introduction 150 6.2 Data sources 151 6.3 Using data to improve the treatment of tobacco dependence in the NHS 165 6.4 Summary 169 7 Teaching and training in smoking cessation 174 7.1 Introduction 174 iv © Royal College of Physicians 2018 Contents 7.2 Undergraduate training of healthcare professionals 174 7.3 Postgraduate training of doctors via specialist medical colleges 178 7.4 Postgraduate training of other healthcare professionals 184 7.5 Training of ‘non-professionalised’ groups such as healthcare assistants 189 7.6 Awareness of smoking cessation interventions among practising healthcare professionals 189 7.7 Training by the National Centre for Smoking Cessation and Training 191 7.8 Summary 194 8 Smoke-free NHS estates 197 8.1 The NHS estate 197 8.2 Smoke-free legislation in the general population 197 8.3 Smoke-free policy in NHS settings 198 8.4 Why an NHS smoke-free estate is necessary 201 8.5 Implementing smoke-free estates in the NHS 202 8.6 The role of electronic cigarettes 208 8.7 Return on investment from introducing smoke-free estates 210 8.8 Conclusion 213 8.9 Summary 213 9 The ethics of health service engagement in the treatment of tobacco dependence 219 9.1 Autonomy and justice 219 9.2 Treating smokers in primary and secondary care 221 9.3 Opt-in and opt-out models 221 9.4 Efficient and effective use of resources 222 9.5 The health system 223 9.6 Correcting the system 223 9.7 Summary 224 10 Conclusions and summary 226 10.1 Introduction 226 10.2 Smoking, death and disease 226 10.3 The cost of smoking to NHS secondary care 227 10.4 How should tobacco dependency by treated in the NHS? 227 10.5 Commissioning stop smoking treatments 228 10.6 Using data to drive improvement 229 10.7 Teaching and training the NHS workforce about smoking cessation 229 © Royal College of Physicians 2018 v Treating tobacco dependency in the NHS 10.8 Keeping NHS grounds smoke free 230 10.9 The ethics of health service engagement in the treatment of tobacco dependence 230 10.10 Summary 231 vi © Royal College of Physicians 2018 Members of the Tobacco Advisory Group of the Royal College of Physicians Sanjay Agrawal Deborah Arnott Richard Ashcroft John Britton (chair) Tim Coleman Linda Cuthbertson Martin Dockrell Anna Gilmore Nick Hopkinson Martin Jarvis Jo Leonardi-Bee Ann McNeill Wendy Preston © Royal College of Physicians 2018 vii Contributors Sanjay Agrawal Consultant in respiratory & intensive care medicine, University Hospitals of Leicester NHS Trust Will Anderson Research consultant, Action on Smoking and Health Colin Angus Research fellow, University of Sheffield Richard Ashcroft Professor of bioethics, Queen Mary University of London Abtesam Askandar Postgraduate student, University of Nottingham Vadsala Baskaran Clinical research fellow, University of Nottingham Linda Bauld Professor of health policy, University of Stirling Alex Bobak General practitioner specialist in smoking cessation, Wandsworth Medical Centre, London Alan Brennan Professor of health economics and decision modelling, University of Sheffield Allison Brisbane Head of research information and policy, ASH Scotland John Britton Professor of epidemiology, University of Nottingham Tim Coleman Professor of primary care, University of Nottingham Elen de Lacy PhD student, Cardiff University Avril Devaney Director of nursing and therapies, Cheshire and Wirral Partnership NHS Foundation Trust Martin Dockrell Tobacco control lead, Public Health England Duncan Gillespie Research fellow, University of Sheffield Allan Gregory Tobacco control programme manager, Public Health England Nick Hopkinson Reader in respiratory medicine, Imperial College London Abby Hunter Research fellow, University of Nottingham viii © Royal College of Physicians 2018 Contributors John Hutchinson Consultant respiratory physician, Sherwood Forest Hospitals NHS Foundation Trust Matthew Jones Assistant professor in health economics, University of Nottingham Emma Knowles Head of policy and research, Healthcare Financial Management Association Tessa Langley Associate professor in health economics, University of Nottingham Hannah Lawrence Clinical research fellow, Nottingham University Hospitals NHS Trust Jo Leonardi-Bee Professor of medical statistics and epidemiology, University of Nottingham Wei Shen Lim Consultant respiratory physician, Nottingham University Hospitals NHS Trust Andy McEwen Chief executive, National Centre for Smoking Cessation and Training Tricia McKeever Professor of epidemiology and medical statistics, University of Nottingham Ann McNeill Professor of tobacco addiction, Kings College London Hayden McRobbie Professor in public health interventions, Queen Mary University of London Ann Morgan PhD student, Imperial College London Rachael Murray Associate professor