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ASH Argues Quitting Programs Save $$s [07/24-5]
Excerpts from: Tackling smoking 'could save millions' BELOW:
Official Summary and Links to Entire Report
BBC News [07/24/00]
Smoking causes many different diseases
The NHS could save huge sums of money by
persuading people to give up smoking,
according to a report.
The anti-smoking charity Action on Smoking
and Health (ASH) says that helping smokers
quit is one of the most cost-effective
measures the NHS could take.
However, it says that such measures attract a
low priority from most health authorities and
doctors.
The report shows that although smoking
cessation expenditure is 12 times as
cost-effective as spending on cholesterol
lowering drugs, the NHS spends 17 times as
much on these drugs as on smoking cessation.
Dr Ann McNeill, co-author of the ASH report,
said tackling smoking was effectively treating
50 diseases associated with the habit before
they actually happen.
She said: "If the NHS tackles heart disease by
prescribing long term medication or through
heart surgery, rather than dealing with the
most obvious risk factor, it is simply wasting
money."
The ASH report recommends:
* action at all levels in the NHS to tackle smoking
* all proven drug treatments, including nicotine replacement
therapy,
to be available on prescription
* clear guidance to health authorities on the economics of
smoking cessation
* referral to the National Institute for Clinical Excellence of the economics
of
smoking cessation
* funding by challenging tobacco taxation directly back to the smoker
* clear guidance on prescribing
* improved integration of specialist and mainstream services
Smoking Cessation in Primary Care summary - July 2000
To see the entire report, click here: ASH
- Mission
Ann McNeill and Clive Bates
Purpose. This document has been prepared in anticipation of the
Government's modernisation review of the NHS announced after the
March 2000 Budget, and forthcoming decisions on the availability of
smoking cessation pharmaceuticals on reimbursable NHS
prescription.
Recognise smoking cessation as rational public spending. The Government
already acknowledges smoking cessation
expenditure to be highly cost effective, yet expenditure on smoking
cessation is parsimonious compared to other less cost-effective
treatments. Furthermore, most smoking cessation pharmaceutical
aids are ‘black-listed’ not available on NHS reimbursable
prescriptions from the general practitioner. We argue that
there should be greater emphasis on smoking cessation in primary care
and that proven smoking cessation products should be available on reimbursable
prescriptions.
Make smoking cessation integral to NHS modernisation. Following
significant extra funding to the NHS, the Government has
instigated a modernisation and reform agenda to ensure new funds give
the greatest possible health and welfare return. Part of this
review is to consider preventative actions and the problem of health
inequalities. In this paper we argue that much greater emphasis
on smoking cessation in primary care is an essential and economically
rational component of modernisation. Agencies involved would
include:
· Commissioners,
such as Health Authorities, Primary Care Groups and Trusts should commission
and audit routine smoking
cessation interventions in primary care contracts. They
should encourage multi-disciplinary involvement in smoking cessation
interventions and integrate these with the new smoking
cessation services.
· Health Authorities,
which should spend funds beyond those granted under the White Paper, Smoking
Kills, (£20m in 2000-01) for
specialist smoking cessation services. Smoking cessation
should be a mandatory component of Health Improvement
Programmes (HIMPs) and written into contracts.
· Specialist
smoking cessation services, set up following the tobacco white paper, Smoking
Kills, should be integrated with
smoking cessation interventions given by general practitioners
and other primary care professionals. Specialist smoking
cessation services should be seen as an important
referral service by general practitioners. New prescribing developments
should enable arrangements to be made for specialist services
to prescribe both bupropion and NRT as ‘dependent prescribers’.
· The National
Institute for Clinical Excellence (NICE), which should provide definitive
guidance on the prescribing protocols for
pharmaceutical smoking cessation treatments and provide
advice on cost-effectiveness so that Health Authorities or primary care
groups can make informed judgements about spending on
smoking cessation drugs and services.
· The Health
Development Agency (HDA), which should advise on which elements identified
in the National Service Frameworks for
Coronary Heart Disease and Cancer (when it is published)
offer the most cost effective approach.
· The Commission
for Health Improvement (CHI), which should ensure providers are responding
adequately to the National Priorities
Guidance, and National Service Framework for CHD.
· Pharmacies,
which are increasingly offering interventions and may have an increased
prescribing role in the future.
· Nurses, who
could receive training through continued professional development.
Large numbers of nurses will be entering the
NHS over the coming years and this presents an excellent
opportunity. Nurses may also have an increased prescribing role in the
future.
· Other health
professionals such as dentists who are encouraged to advise smokers to
stop on as routine a basis as possible.
· Professional
bodies which could influence the content of health professional undergraduate,
graduate and postgraduate training
and ensure smoking cessation training is accredited.
· NHS Trusts
and hospitals, which should have a proactive approach to smoking cessation
for all patients that enter the hospital as
smokers. One way forward could be for the Department of
Health or NHS Executive to endorse a charter and accreditation
scheme to encourage such an approach.
· NHS Direct,
including giving brief opportunistic interventions to smokers over the
telephone as well as advice to ring the Smokers’
Helpline.
Avoid inefficiency and waste by correctly aligning spending and cost-effectiveness.
As an example of the misalignment in
expenditure, figures cited by Ministers show that twelve times as much
money (£245m compared to £20m) is spent on statins
(cholesterol-lowering heart disease treatments) with average cost effectiveness
of only about one-seventeenth smoking cessation
(£9,350 compared to £543 per life year saved). Greater
expenditure on smoking cessation could reduce expenditure on statins by
reducing heart disease risk to below the level at which treatment with
statins is no longer recommended. This kind of trade-off is not
currently made in NHS planning and is effectively a major source of
waste.
Use smoking cessation in primary care as a key strategy in tackling
health inequalities. Smoking is the major cause of health
inequalities two-thirds of the social class gradient of premature
mortality is attributable to smoking. The Government has a target to
reduce social class inequalities in smoking prevalence. Whilst
recognising the importance of broad government measures to tackle
the causes of deprivation, specific action also needs to be taken to
support deprived smokers needing to quit. Current smoking
cessation services are unlikely to address health inequalities because
they would need to create a much greater uptake from the
poorest groups. We argue that smoking cessation services
offered proactively in primary care are more likely to reach the poorest
smokers. Many potential objections have been raised to greater
GP involvement - notably time and incentives - however we document
three schemes within the general practice team that work very well
with little extra cost. The main requirement is to have a clear
treatment protocol within which GPs and others in primary care can
operate. It is notable also that all three of these schemes involve
prescribing of NRT products and that if all these products were blacklisted
they could fail.
Introduce reimbursable prescribing for NRT and bupropion. We argue
that all proven smoking cessation treatments should be
available on NHS reimbursable prescriptions. There are no compelling
arguments to deny the GP the option to treat tobacco
dependence with proven cost-effective drugs. This should apply
both to all NRT products including combinations, and to the new
treatment, bupropion hydrochloride (trade name: Zyban). Making these
products available on NHS reimbursable prescriptions would
ensure the poorest smokers have access to them. On 27th June
2000, the Government announced that bupropion would be made
available on NHS reimbursable prescription - a decision widely welcomed
by the health community. No announcement was made
about prescribing for NRT.
Ensure equity between bupropion and NRT. It is recommended that
the reimbursement arrangements for the two types of
smoking cessation treatment are as far as possible equitable. If only
bupropion is available on NHS reimbursable prescriptions, this
would undermine the perceived efficacy and uptake of NRT by both smokers
and health professionals alike and therefore affect the
primary care and over-the-counter markets for NRT(see below). It would
limit the choice of treatments that GPs can give and not allow
them to tailor the pharmacological treatment to the smoker. On the
basis of its public acknowledgement of the evidence for efficacy
and cost efficiency, we believe that the Government may be exposed
to judicial review if it blacklists NRT. If bupropion is available only
through primary care, this could undermine the new smoking cessation
services by attracting smokers away from them. We
recommend that new prescribing developments should enable services
to prescribe bupropion as ‘dependent prescribers’.
Use an abstinent-contingent treatment protocol. A strong case can be
made on cost-effectiveness grounds for a prescribing
protocol based on the abstinent-contingent treatment (ACT) model.
This would involve renewing supplies of NRT and bupropion up to a
maximum allowance, only if the patient is abstinent from smoking or
continuing to conform to an agreed smoking cessation
programme.
Maintain the OTC market for nicotine replacement therapies. There is
a £56 million over-the-counter market for smoking
cessation pharmaceuticals. It is desirable to retain this private-sector
consumer expenditure, and the advertising that it generates
thought to be worth about £14.5 million. It is far from
certain that the £56m OTC market would transfer to the public sector
(if NRT was
to be reimbursed) as the time involved in GP appointments would probably
deter many smokers. However, it would be possible,
although less equitable, to target a different population to those
currently purchasing OTC by giving NRT a ‘Schedule 11’ listing. This
could involve the product being prescribed only to people with pre-existing
heart or respiratory conditions, or other targeted
populations. Another alternative would be to limit NHS prescriptions
to those eligible to be in receipt of free prescriptions. In addition,
the reimbursed price should not be set at a level so low that it effectively
renders the OTC market unviable - this could be achieved by
GPs continuing to prescribe branded rather than generic NRT products.
Acknowledge the potential neutral impact on drugs bill. There have
been a number of attempts to predict the scale of
expenditure that would arise from public funding of smoking cessation
treatments. However, the method of funding drugs expenditure
has changed greatly in the last few months. Allowing reimbursable
prescribing of smoking cessation pharmaceuticals would not in
itself increase NHS expenditure. The drugs budget is now part
of cash-limited expenditure and primary care groups are required to
stay within budget. The impact of allowing prescribing with no
budget increase would be to allow changes in prioritisation. We
advocate increased total expenditure, as well as a re-alignment of
priorities.
Fund a comprehensive smoking cessation service nationally. It has been
estimated that a fully funded smoking cessation
service including brief-advice, self-help, free provision of NRT (on
a contingent abstinent basis) and bupropion and specialist smoking
cessation clinics could be implemented nationally at a cost not exceeding
£118 million. This is £88 million more than the monies
currently granted in the third year of the White Paper programme (£30
million). This would either be found from reprioritising existing
expenditure to more cost-effective smoking cessation, or from net additional
expenditure, of from a combination.
Fund smoking cessation expenditure from tobacco taxation. The Chancellor
has accepted the principle of hypothecating
increases in tobacco revenue to the NHS. We believe that for
a number of reasons, a share of the tobacco tax should be returned
directly to smokers as smoking cessation expenditure. From the
point of view of tobacco taxation policy, these reasons are:
· An ethical
obligation to maximise smoking cessation opportunities if high and increasing
taxes are to be levied on an addictive
drug
· An extension
of the Chancellor’s principle of fairness in taxation
· Good presentational
value as a populist measure
We believe that all the extra expenditure required (£88 million)
would be around 30 percent of the increase in tobacco tax made in the
March 2000 budget, or equivalent to just 1.5 percent real increase
in tobacco duty. This is around one-tenth of the duty increases
since the Labour government came into office.
Review the licensing system for pharmacological smoking cessation treatments.
Pharmacological smoking cessation
treatments undergo assessment through the Medicines Control Agency
(MCA) which licenses the products according to its standard
criteria (efficacy and safety) with no reference to the scale of the
public health problem caused by cigarettes. We recommend that
where appropriate pharmacological smoking cessation treatments
most forms of NRT - should be available on general sale, the
regulatory process for dealing with changes to the treatments should
be reduced whilst maintaining quality controls and research and
development in this area should be encouraged.
Co-signatories:
Organisations
Cancer Research Campaign
National Heart Forum
No Smoking Day
Pharmacy Healthcare Scheme
QUIT
Royal College of Nursing
Royal College of Physicians
UK Public Health Association
Individuals
Dr Claire Anderson, Director of Pharmacy Practice and Social Pharmacy,
The Pharmacy School, University of Nottingham
Professor John Britton, Division of Respiratory Medicine, University
of Nottingham
Dr Tim Coleman, Clinical Lecturer, Department of General Practice and
Primary Health Care, University of Leicester
Dr Jonathan Foulds, Senior Lecturer, Department of Psychology, University
of Surrey
Professor Godfrey Fowler. Emeritus Professor of General Practice, University
of Oxford
Professor Christine Godfrey, University of York.
Professor Martin Jarvis, Imperial Cancer Research Fund Health Behaviour
Unit, Department of Epidemiology and Public Health,
University College London
Tim Lancaster, Department of Primary Health Care, Institute of Health
Sciences, Oxford
Dr Kevin Lewis, Clinical Director of Smoking Cessation, Shropshire
Health Authority
Dr Martin Raw, Honorary Senior Lecturer, Department of Public Health
Sciences, Guys Kings and St Thomas’ School of Medicine,
University of London
John Stapleton, National Addiction Centre, Institute of Psychiatry,
London
Gay Sutherland, Hon. Consultant Clinical Psychologist, Maudsley Hospital
Smokers Clinic/National Addiction Centre, London
Professor Robert West, Department of Psychology, St George’s Medical
School, London
The Commission for Health Improvement although unable to be a co-signatory
has expressed its
support for the arguments and recommendations contained in this document.
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2013 H Street, N.W., Wash., DC 20006, USA, (202) 659-4310.
ASH is a 31-year-old national legal-action antismoking and nonsmokers'
rights organization which is entirely supported by tax-deductible contributions.
Please credit ASH, and include ASH's web address:
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