Lesley Owen

Impact of a telephone helpline for smokers who called during a mass media campaign

OBJECTIVE To evaluate the impact of a telephone helpline (Quitline) with additional support (written information) on callers who use the service during a mass media campaign. DESIGN Telephone recall surveys of callers to the helpline carried out two months and one year after their initial call. SETTING Telephone helpline. SUBJECTS Callers to the helpline. MAIN OUTCOME MEASURES Smoking behaviour change among callers to the helpline at two months and one year. RESULTS At one year 22% (95% confidence interval (CI) 18.4% to 25.6%) of smokers reported that they had stopped smoking. Assuming that those who refuse to take part in the one year follow up are continuing smokers and a further 20% of reported successes fail biochemical validation, this yields an adjusted quit rate of 15.6% (95% CI 12.7% to 18.9%) at one year. Among ex-smokers, 41% (95% CI 34.3% to 47.7%) reported that they were still not smoking at one year. The adjusted figure for ex-smokers at one year is 29% (95% CI 23.3% to 34.8%). Of those who resumed smoking 28% were smoking less than they had been initially. Currently Quitline receives around half a million calls in the course of one year, 93% of whom are phoning for themselves. This represents 4.2% of the total population of adults smokers in England. CONCLUSION The Health Education Authoritys advertising campaign was extremely successful in generating calls to the helpline. Very large numbers of smokers from diverse backgrounds, including the key groups highlighted in the UK governments recent proposals on tobacco, called the Quitline, which appeared to be very successful in helping these callers to stop smoking. For a single intervention to reach 4.2% of the total population of adult smokers in England is a major achievement. This makes Quitline a very promising model for public health intervention programs.

The cost-effectiveness of public health interventions

BACKGROUND The need to make best use of limited resources in the English National Health Service is now greater than ever. This paper contributes to this endeavour by synthesizing data from cost-effectiveness evidence produced to support the development of public health guidance at the National Institute of Health and Clinical Excellence (NICE). No comprehensive list of cost-effectiveness estimates for public health interventions has previously been published in England. METHODS Cost-effectiveness estimates using English cost data were collected and analysed from 21 (of 26) economic analyses underpinning public health guidance published by NICE between 2006 and 2010. RESULTS Two hundred base-case cost-effectiveness estimates were analysed, 15% were cost saving (i.e. the intervention was more effective and cheaper than comparator). Eighty-five per cent were cost-effective at a threshold of £20,000 per quality-adjusted life year and 89% at the higher threshold of £30,000. A further 5.5% were above £30,000 and 5.5% of the interventions were dominated (i.e. the intervention was more costly and less effective than comparator). CONCLUSIONS The majority of public health interventions assessed are highly cost-effective. The next challenge is to provide commissioners with a framework that allows information from economic analyses to be combined with other criteria that supports making better investment decisions at a local level.

Known knowns, known unknowns, unknown unknowns: The predicament of evidence-based policy

The authors present a case study examining the potential for policies to be “evidence-based.” To what extent is it possible to say that a decision to implement a complex social intervention is warranted on the basis of available empirical data? The case chosen is whether there is sufficient evidence to justify banning smoking in cars carrying children. The numerous assumptions underpinning such legislation are elicited, the weight and validity of evidence for each is appraised, and a mixed picture emerges. Certain propositions seem well supported; others are not yet proven and possibly unknowable. The authors argue that this is the standard predicament of evidence-based policy. Evidence does not come in finite chunks offering certainty and security to policy decisions. Rather, evidence-based policy is an accumulative process in which the data pursue but never quite capture unfolding policy problems. The whole point is the steady conversion of “unknowns” to “knowns.”

How cost-effective is ‘No Smoking Day’?

Objective To obtain a more rigorous estimate of the cost-effectiveness of No Smoking Day (NSD), an annual UK-wide campaign to encourage smokers to quit, than has been possible hitherto. Design Comparison of reported quit attempts in the month following NSD for three consecutive years with adjacent months using repeated national surveys of quit attempts. Setting England. Participants A total of 1309 adults who had smoked in the past year who responded to the surveys in the month following NSD (April 2007–2009) and a comparison group of 2672 adults who smoked in the past year who responded to the survey in the two adjacent months (March and May 2007–2009). Main outcome measures The number of additional smokers who quit permanently in response to NSD was estimated from the survey results. The incremental cost-effectiveness ratio (ICER) was calculated by combining this estimate with established estimates of life years gained and the known costs of NSD. Results The rate of quit attempts was 2.8 percentage points higher in the months following NSD (120/1309) compared with the adjacent months (170/2672; 95% CI 0.99% to 4.62%), leading to an estimated additional 0.07% of the 8.5 million smokers in England quitting permanently in response to NSD. The cost of NSD per smoker was £0.088. The discounted life years gained per smoker in the modal age group 35–44 years was 0.00107, resulting in an ICER of £82.24 (95% CI 49.7 to 231.6). ICER estimates for other age groups were similar. Conclusions NSD emerges as an extremely cost-effective public health intervention.

Best practice in smoking cessation services for pregnant women: results of a survey of three services reporting the highest national returns, and three beacon services:

Aims: The NHS allocated dedicated funds to establish specialist smoking cessation services for pregnant smokers in England in 2000. An early survey revealed some uncertainty as to how the new services should work and monitor their outcome. The current survey focused on identifying examples of good practice in this difficult new field. Method: Three services with the highest number of successful four-week quitters reported for the 2003/4 monitoring year were identified from Department of Health (DH) monitoring records, and three services were nominated from those known in the field as examples of best practice. There was no overlap between the two groups. All six services provided in-depth interviews. Results: All three highest ranking services that reported close to 100 per cent success rates included unaided quitters identified from hospital wards, rather then smokers actually treated. They had only minimal or average genuine treatment provision for pregnant smokers in place. The three beacon services far exceeded the national throughput and outcome average identified in the previous survey, and provided a wealth of useful information. Although they differed in staffing levels and other aspects of their activities, they all shared several key elements, including a systematic training of midwives in how to refer pregnant smokers, offering nicotine replacement treatment to almost all clients and having an efficient system of providing the prescriptions, offering flexible home visits, and providing intensive multi-session treatment delivered by a small number of dedicated staff. Conclusion: Smoking cessation services for pregnant women may need clearer guidance on what they are expected to provide, and how they should monitor their outcome. The key features of the beacon services can serve as a practical model of current best practice applicable across most PCTs.

Estimates of effectiveness and reach for ‘return on investment’ modelling of smoking cessation interventions using data from England

Abstract Background and aims Estimating ‘return on investment’ (ROI) from smoking cessation interventions requires reach and effectiveness parameters for interventions for use in economic models such as the EQUIPT ROI tool (http://roi.equipt.eu). This paper describes the derivation of these parameter estimates for England that can be adapted to create ROI models for use by other countries. Methods Estimates were derived for interventions in terms of their reach and effectiveness in: (1) promoting quit attempts and (2) improving the success of quit attempts (abstinence for at least 12 months). The sources were systematic reviews of efficacy supplemented by individual effectiveness evaluations and national surveys. Findings Quit attempt rates were estimated to be increased by the following percentages (with reach in parentheses): 20% by tax increases raising the cost of smoking 5% above the cost of living index (100%); 10% by enforced comprehensive indoor public smoking bans (100%); 3% by mass media campaigns achieving 400 gross rating points (100%); 40% by brief opportunistic physician advice (21%); and 110% by use of a licensed nicotine product to reduce cigarette consumption (12%). Quit success rates were estimated to be increased by the following ratios: 60% by single‐form nicotine replacement therapy (NRT) (5%); 114% by NRT patch plus a faster‐acting NRT (2%);124% by prescribed varenicline (5%); 60% by bupropion (1%); 100% by nortriptyline (0%), 10) 298% by cytisine (0%); 40% by individual face‐to‐face behavioural support (2%); 37% by telephone support (0.5%); 88% by group behavioural support (1%); 63% by text messaging (0.5%); and 19% by printed self‐help materials (1%). There was insufficient evidence to obtain reliable, country‐specific estimates for interventions such as websites, smartphone applications and e‐cigarettes. Conclusions Tax increases, indoor smoking bans, brief opportunistic physician advice and use of nicotine replacement therapy (NRT) for smoking reduction can all increase population quit attempt rates. Quit success rates can be increased by provision of NRT, varenicline, bupropion, nortriptyline, cytisine and behavioural support delivered through a variety of modalities. Parameter estimates for the effectiveness and reach of these interventions can contribute to return on investment estimates in support of national or regional policy decisions.

Myths, facts and conditional truths: What is the evidence on the risks associated with smoking in cars carrying children?

The CMAJ recently carried a spirited exchange on the dangers to children exposed to second-hand smoke in cars. MacKenzie and Freeman showed how an unsubstantiated statistic (that second-hand smoke was 23 times more toxic in a vehicle than in a home) had acquired mythical status thanks to widespread

Smoking before, during and after pregnancy in England

Separate surveys were conducted among pregnant women (N = 625) and new/recent mothers (N = 550) throughout England. Smoking prevalence among pregnant women was found to be linked to age, social grade, educational attainment, employment status, pregnancy planning and partners smoking status. Possible links were also detected between smoking prevalence and number of previous pregnancies and number of miscarriages. Among those smoking during pregnancy or within 12 months before pregnancy, there was a greater likelihood of reducing consumption (35 per cent) than giving up altogether (26 per cent). Among those cutting down, consumption decreased from an average rate of 18.2 to 12 cigarettes/day. Thirty-five per cent of pregnant women in the home, and 45 per cent of pregnant women in the workplace, were exposed to passive smoking. Of children whose father or mother smoked, 44 per cent were exposed to passive smoking from their parents. The majority of both samples considered smoking to be dangerous to the foetus (86 per cent of pregnant women) and their newly born child (96 per cent of new/recent mothers) and were aware of passive smoking and its danger. Of the partners of pregnant women, and of new/recent mothers, 39 per cent and 36 per cent respectively were reported to be smokers.

Smoking Cessation: A Comparison of Two Model Structures

BackgroundMost economic evaluations of smoking cessation interventions have used cohort state-transition models. Discrete event simulations (DESs) have been proposed as a superior approach.ObjectiveWe developed a state-transition model and a DES using the discretely integrated condition event (DICE) framework and compared the cost-effectiveness results. We performed scenario analysis using the DES to explore the impact of alternative assumptions.MethodsThe models estimated the costs and quality-adjusted life years (QALYs) for the intervention and comparator from the perspective of the UK National Health Service and Personal Social Services over a lifetime horizon. The models considered five comorbidities: chronic obstructive pulmonary disease, myocardial infarction, coronary heart disease, stroke and lung cancer. The state-transition model used prevalence data, and the DES used incidence. The costs and utility inputs were the same between two models and consistent with those used in previous analyses for the National Institute for Health and Care Excellence.ResultsIn the state-transition model, the intervention produced an additional 0.16 QALYs at a cost of £540, leading to an incremental cost-effectiveness ratio (ICER) of £3438. The comparable DES scenario produced an ICER of £5577. The ICER for the DES increased to £18,354 when long-term relapse was included.ConclusionsThe model structures themselves did not influence smoking cessation cost-effectiveness results, but long-term assumptions did. When there is variation in long-term predictions between interventions, economic models need a structure that can reflect this.

Assessment of cost-effective changes to the current and potential provision of smoking cessation services: an analysis based on the EQUIPTMOD: Cost-effectiveness of smoking cessation

Abstract Background and aims Increasing the reach of smoking cessation services and/or including new but effective medications to the current provision may provide significant health and economic benefits; the scale of such benefits is currently unknown. The aim of this study was to estimate the cost‐effectiveness from a health‐care perspective of viable national level changes in smoking cessation provision in the Netherlands and England. Methods A Markov‐based state transition model [European study on Quantifying Utility of Investment in Protection from Tobacco model (EQUIPTMOD)] was used to estimate costs and benefits [expressed in quality‐adjusted life years (QALY)] of changing the current provision of smoking cessation programmes in the Netherlands and England. The changes included: (a) increasing the reach of top‐level services to increase potential quitters (e.g. brief physician advice); (b) increasing the reach of behavioural support (group‐based therapy and SMS text‐messaging support) to increase the success rates; (c) including a new but effective medication (cytisine); and (d) all changes implemented together (combined change). The costs and QALYs generated by those changes over 2, 5, 10 years and a life‐time were compared with that of the current practice in each country. Results were expressed as incremental net benefit (INB) and incremental cost‐effectiveness ratio (ICER). A sequential analysis from a life‐time perspective was conducted to identify the optimal change. Results The combined change was dominant (cost‐saving) over all alternative changes and over the current practice, in both countries. The combined change would generate an incremental net benefit of €11.47 (2 years) to €56.16 (life‐time) per smoker in the Netherlands and €9.96 (2 years) to €60.72 (life‐time) per smoker in England. The current practice was dominated by all alternative changes. Conclusion Current provision of smoking cessation services in the Netherlands and England can benefit economically from the inclusion of cytisine and increasing the reach of brief physician advice, text‐messaging support and group‐based therapy.