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Optimising tobacco dependency services in secondary care

Tobacco dependency and e-cigarettes are never far from the headlines, and while progress is being made across the UK, there’s still a long way to go to ensure a consistent approach to smoking cessation support in secondary care. Here, Dr Zaheer Mangera, respiratory consultant at North Middlesex University Hospital, speaks to clinical writer Rod Tucker and shares his insights and advice around best practice.

Dr Zaheer Mangera is a respiratory consultant at North Middlesex University Hospital, where his main scope of practice is lung cancer, though he also sees patients with other respiratory diseases such as asthma and COPD.

He has a strong interest in tobacco dependency and is chair of the British Thoracic Society’s tobacco specialist advisory group. In addition to his clinical role, Dr Mangera is also involved in undergraduate medical education, teaching at University College London medical school.

As the lung cancer lead at North Middlesex University Hospital, part of Dr Mangera’s role is to maintain overall responsibility for the National Optimal Lung Cancer Pathway. Developed in 2017, it aims to improve and streamline the patient pathway to enable a more prompt diagnosis of those with lung cancer at the earliest possible stage when, of course, treatment is most effective.

‘You’re trying to get everyone diagnosed with cancer and treatment within 49 days of a referral being made of a suspected cancer,’ he says. And while he sees this target as quite challenging, it is evidence-based and therefore worth pursuing. An additional component of the pathway is the requirement to support those who continue to smoke when presenting with suspected lung cancer and encouraging cessation.

Another area of work that consumes a good deal of Dr Mangera’s time is spent on imaging interpretation. ‘The chest gets scanned for all sorts of different reasons and I spend a lot of time looking at incidental findings, which require someone to take a look and make a decision as to whether they need to be taken forward or whether they can be dismissed,’ he says.

Explaining these findings to patients can often pose a challenge, particularly when benign lung nodules are identified. ‘More than 90% of lung nodules under 1cm are not cancer, and most patients are able to understand and appreciate that the overall risk is low and recognise the need that some [nodules] will need follow-up,’ Dr Mangera explains. This could be further scanning over the next two years or an extended follow-up period of four years.

Interventions for tobacco dependency

In September 2023, a Cochrane review updated its earlier findings on the most effective pharmacological interventions for smoking cessation in adults. They key messages centred on the fact that all available treatments are effective, albeit with varying degrees of success.

Interestingly, the Cochrane review found that e-cigarettes and varenicline have a success rate with an additional seven to eight more quitters per 100 when compared to control, which is slightly higher than combination nicotine replacement therapy (NRT). Dr Mangera believes that irrespective of the intervention, ‘the most important thing is that it’s being used to its maximum benefit’.

He proposes that part of the reason why established interventions such as NRT fail, is because ‘it’s not matching the needs of the patient who is trying to stop smoking, and it is very common for individuals to be underdosed and not getting a sufficiently strong background amount of nicotine’.

Specialist smoking cessation services

Over the years, Dr Mangera has come to appreciate the importance of having appropriately trained staff who are able to deliver additional advice for those wishing to stop smoking. Unfortunately, the provision of this specialist advice throughout the NHS is patchy.

‘My hospital is served by four different boroughs, but of the two main boroughs, one does have a stop smoking service whereas the other borough doesn’t have such a service. It’s a genuine postcode lottery as to how I can support patients. One group will be called up within a week and get access to specialist advice, whereas the other gets no support at all,’ he explains.

Specialist advice, often in the form of motivational interviewing, is a recognised strategy for increasing an individual’s success at smoking cessation. ‘That’s where you need the whole package. Just giving somebody the drugs and sending them on their way, the success rate is between 10 and 20%, but that is certainly better than willpower alone, which can be 2-3%,’ says Dr Mangera.

When patients receive a pharmacological intervention as well as specialist advice, ‘they are three times more likely to be successful in stopping smoking’, he adds.

Though NRT has slightly lower quit rates, Dr Mangera believes that the easy access to these products through pharmacies, supermarkets and online shops makes it a very worthwhile option to signpost to smokers.

The NHS long-term plan

The likelihood that a patient will stop smoking can dramatically change if there is a significant life event such as hospitalisation. Such an event often makes current smokers acutely aware of the adverse health sequalae linked to their smoking.

This transtheoretical model includes six different stages moving from starting to consider quitting to complete cessation: precontemplation, contemplation, preparation, action, maintenance or termination.

But one factor that is likely to serve as a motivator for change is a significant life event such as hospitalisation. Such an event often makes current smokers acutely aware of the adverse health sequalae linked to their smoking.

Dr Mangera clarifies: ‘When you are an inpatient, you are twice as likely to want to stop smoking than at other times in your life.’ This provides a huge opportunity for buy-in from patients and a greater willingness to want to quit.

The NHS long-term plan seeks to capitalise on this fact and already includes funding for tobacco dependency treatment for all inpatients who smoke. Dr Mangera says that while the complete rollout of this service is yet to be realised throughout the NHS, there has been considerable engagement to date in many hospitals.

The NHS approach is based on the findings of the Ottawa Model for Smoking Cessation (OMSC) in which quit rates for hospitalised patients supported by this systematic approach to provider-level support ranged from 18-48% after 180 days.

But whereas the NHS plan has been met with some success, Dr Mangera describes how it seems that the NHS has gone full circle. In the past, he says, a number of specialist tobacco advisors were recruited but then ‘the service was de-funded’ and rebuilding the expertise of the past is challenging and time consuming.

‘You can’t just find tobacco advisors off the shelf. The period of training that’s required can take weeks, if not months,’ he says. Consequently, the whole process of recruitment and development of a business case can take many months before a service is up and running.

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A further problem he outlines is that aspects of the NHS long-term plan were introduced during the Covid-19 pandemic, and with the current strikes by medical staff and increased waiting times, the full implementation has been hampered.

Developing tobacco dependency support services

That being said, Dr Mangera cites the success of The CURE Project – a secondary care treatment programme for tobacco addiction in Greater Manchester.

The project systematically identifies all active smokers admitted to secondary care and offers NRT and other medications, as well as specialist support, for the duration of the admission and after discharge.

Preliminary results reveal that of nearly 2,400 individuals identified in the project, 22% self-reported that they had stopped smoking 12 weeks later. Dr Mangera believes that with the necessary political willpower and funding there is little reason to suggest that the success of the CURE project could not be replicated across England and perhaps beyond.

That’s not to say, however, that there wouldn’t be challenges to overcome with the wider rollout of an in-patient tobacco dependency service. Dr Mangera identifies one such logistical challenge as access to an appropriate IT system to help identify current smokers. This problem is further compounded by the fact that hospitals often use different systems with dissimilar methods of reporting the data, he says.

Recruitment and training

A much more challenging issue is recruitment and training of the necessary workforce. Even the training of doctors he feels will be difficult to embed within the current undergraduate medical curriculum.

‘Every single speciality wants to put their bit into the curriculum, so trying to create that consistency across medical schools is not easy,’ he says.

Though all doctors will receive some degree of training in smoking cessation as undergraduates, in reality, this knowledge does not appear to be utilised in practice. Dr Mangera cites British Thoracic Society National Secondary Care audits that demonstrate that a patient’s smoking status is often not being recorded in secondary care and smokers are often not offered any form pharmacotherapy or even referred to a specialist service.

In short, he believes that the limited training in the delivery of smoking cessation advice is compounded by the fact that ‘newly qualified doctors are not entering a hospital where systems are in place to make these things as easy as possible’. Furthermore he emphasises the importance of framing this as ’everybody’s business’, as all healthcare providers should be trained in offering patients advice and direction on how they can access stop smoking support.

But it’s not all doom and gloom. Where tobacco dependency services have been established in some hospitals, several important aspects attributed with successful implementation are evident.

For example, Dr Mangera believes that strong leadership from a senior clinician or a member of the executive team, with direct responsibility for the service, is a must. Repositories of information, such as detailed guidelines and protocols, are also vital to allow clinical staff to quickly get up to speed with the service and ensure consistent delivery.

Support for healthcare professionals

With a lack of specialist advisors, it becomes all the more necessary to ensure secondary care professionals are able to deliver smoking cessation advice to in-patients. Dr Mangera says that a short, online smoking cessation course, such as those developed by the National Centre for Smoking Cessation and Training, can be used train health professionals on the delivery very brief smoking cessation advice.

He adds that all doctors – and ideally all patient facing healthcare professionals – should be able to ask patients about their smoking status and offer advice and, where appropriate, have NRT prescribed within the first 24 hours. These patients may be able to experience a temporary smoking abstinence, which will improve their inpatient experience and reduce the effects of withdrawal, as well as signpost the impact of smoking on their overall health.

In addition, because many NRT products are freely available over the counter, some centres have adopted a home remedy approach. In other words, hospitalised patients are not denied access to products that are available to the wider public and accessible during their hospital stay and on discharge.

Although once outside of hospital, access a specialist tobacco advisor can be variable, Dr Mangera suggests that patients can turn to either the national or regional smoking cessation services. Whilst not able to provide a full package, patients are always able to access ‘some form of support’, he says.

Use of electronic cigarettes

Although e-cigarettes have been available for many years, Dr Mangera feels that these products represent an important component of smoking cessation outside of a traditional programme.

‘Vaping is interesting in that it’s a way of reliably delivering nicotine replacement, but there are so many confounding concerns about it that the messaging around vaping is very confusing for patients,’ he says.

There is no doubt that it is safer than cigarettes, and vaping is recognised as having a role by multiple organisations including NICE and the Royal College of Physicians. However, there remain concerns about its uptake in young adults and children and the longer-term impacts on health.

For this reason, vaping has polarised medical opinion. For instance, some doctors consider it to be a much safer option than smoking whereas others are much more apprehensive about its role, particularly as NRT is already widely available. And Dr Mangera is aware of a number of case reports from around the world showing how vaping can lead to lung injury in specific circumstances, although the overall numbers are small.

Despite these concerns, a living Cochrane review suggests e-cigarettes help people to quit smoking better than traditional NRT, and Dr Mangera believes there is a general consensus that vaping is far less harmful than smoking. His personal view is that younger smokers and vapers should be supported with their nicotine addiction with the goal of complete abstinence, but that there is a role for vaping to be used as a harm reduction strategy alone in older smokers, with or without a smoking-related disease, who have considered all other options.

Finally, Dr Mangera says that while there are still teething problems with the national roll-out of the NHS long-term plan and its associated tobacco dependency services, he remains hopeful that this innovation is likely to have a major impact on the quit rates of smokers admitted to hospital in England.

He says that as whole, the UK is performing better than other countries in reducing smoking rates, and legal changes such as the ban of public smoking and strict controls on advertising have the largest impact. Right now, the UK Government is working through a plan to ban smoking completely for future smokers and, for Dr Mangera, this marks a moment in history.

Continued success does require the necessary political commitment to sustained funding, but at the present time, the current direction of travel remains positive.