Stubbing out the public health problem of an era | Blog piece by Tim Coleman | #myresearchlegend

Sir Richard Doll had an illustrious career. Through his efforts, the world learned much about the causes of cancer and the dangers of asbestos, radiation and, of course, smoking. Following his research into smoking and lung cancer during the 1950s, the realisation dawned that tobacco use was the public health problem of the era and not a harmless pastime. We all know what’s happened since. How many other 20th century epidemiologists have had such a transformative impact on peoples’ understanding of the determinants of disease?

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To what extent do I consider Sir Richard Doll to be a research ‘legend’? I’m not sure I’ve earned the right to bestow that honour, so I’ve taken advice. The Cambridge English Dictionary says a ‘legend’ is “someone very famous and admired, usually because of their ability in a particular area”. Just considering the one area of Doll’s work emphasised above, this is a no-brainer; ‘legend’ threshold is clearly surpassed. Don’t take my word for this, though, Google ‘Richard Doll’ and see if you can find reason to disagree.

Am I hasty in allocating ‘legend’ status? Doll certainly changed the world’s knowledge of many illnesses; shouldn’t an NIHR research legend demonstrate clear NHS impact too? Fortunately Doll’s influence here doesn’t disappoint, even if one again only considers smoking. I am a GP. How would this be different if Sir Richard had never lived? Firstly, I’d probably smoke. A pipe would give me more gravitas than cigarettes and I’d have to either smoke in my consulting room, like some doctors did, or schedule regular ‘pipe breaks’ into my day. I would be blissfully ignorant about harms from smoking and more likely to offer patients cigarettes than help with stopping, even if they developed lung cancer or heart disease.

Smoking Kills

Thankfully, Sir Richard did exist. Although I tried smoking as a teenager, a friend’s mum made me think again and I didn’t ever fully adopt the habit. Immature, teenage me was saved from smoking because Doll had shown how harmful smoking is. Fast forward to my GP work in 2018; again due to Doll, I fully realise that smoking kills my patients and wrecks their lives.

crop.jpgAlso, due to research which was only possible because of his early work, I can offer smokers numerous types of cessation support. It’s even possible to refer on to Stop Smoking Services (SSS) for specialist help, though a major cloud on the horizon is that these vital services are no longer universal; they are endangered.

Through their work at the Statistical research Unit of the MRC, Doll and Hill demonstrated that smoking causes lung cancer; before this smoking was ubiquitous across social classes and many doctors smoked. By 1954, the government accepted the link and the middle classes started quitting in droves. When he died in 2005, Doll would very likely have been delighted that UK smoking rates were falling fast. However, improvements were chiefly amongst the better off, so smoking had become disproportionately concentrated amongst society’s poorest. Given his well-documented non-conformist views, my bet is that he would have been saddened that those with most to gain benefited least from such massive social change. Nevertheless, he might have been heartened by the government’s national and vigorous action against smoking. Back then, although SSS were a very new NHS entity, it was mandatory for Primary Care Trusts to deliver them and SSS were closely performance-managed by the then Department of Health. Any smoker could access services’ evidenced-based support to increase their chances of permanent cessation.

Smoking Prevention

Worldwide, legions of researchers, including me, have followed Doll by trying to find ways of treating or preventing smoking. Few epidemiologists have caused such a seismic shift in the international research agenda. Take a look at the thousands of randomised controlled trials (RCTs) reviewed in the tobacco section of the Cochrane Library. All of these studies test interventions against smoking. This necessary work continues today and NIHR is a leading supporter funding, for example, the largest ever RCTs of Nicotine Replacement Therapy used in pregnancy* or for ‘preloading’.

The NHS is 70. Celebrating research legends is a great idea but it’s important we remember what they did and why they are lauded. It took almost half a century after Doll and Hill’s landmark paper for the NHS to implement national treatment services for smokers, and sadly less than 20 years later these have become an optional extra with patchy coverage across the country. Smoking is less prevalent than in the past but there are still millions of UK citizens who want to stop and can’t manage this alone. Smoking is still a national problem and requires a national NHS response. A crucial component of this response should be to help quitters by giving them the very best support.

Sir Richard’s work has had a great impact, as all research should. The demise of SSS suggests we risk forgetting this when instead we should continue to build on his significant achievements.

*More information on the trial: Double-blind, randomised, placebo-controlled trial of nicotine replacement therapy (NRT) in pregnancy – SNAP is available on the NIHR Journals Library website.

Tim Coleman, Professor of Primary Care, Faculty of Medicine & Health Sciences
University of Nottingham and NIHR Senior Investigator

The NIHR is highlighting seven research legends whose work has shaped the NHS, as part of its celebrations for the NHS’s 70th birthday and the NIHR’s I Am Research campaign.

Original post on NIHR website. – Posted: 04 May 2018

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Are you a vaper who also smokes? Would you be willing to help with an important study at QMUL?

How does dual use of e-cigarettes and conventional cigarettes change over time?

The Study:

This study is being run by the Health and Lifestyle Research Unit at Queen Mary University of London, and is funded by Cancer Research UK (CRUK).

Many people who smoke conventional cigarettes also use an e-cigarette and this is called ‘dual use’. Little is known about the way such use develops over time. Most dual users aim to stop smoking altogether, but many people continue using both products. It is not clear at present how many of these dual users stop smoking, at which time point, and what factors help them to stop.

We are inviting up to 500 dual users to take part in a study which aims to gain a greater understanding of these issues. If you take part, we will ask you questions about your vaping and smoking over the telephone or internet at 3 monthly intervals, over a 12-month period. The surveys should take approximately 10 minutes each to complete. You will receive a £15 voucher as compensation for your time. The study is funded for 1 year initially, but if we obtain further funding, we will extend the follow-up period to 10 years.

We hope that the results of this trial will inform what advice doctors and other health professionals give on e-cigarettes in the future.

Who can take part?

You will be able to take part if you are:

  • Aged 18 years or over.
  • Currently using both an e-cigarette and conventional cigarettes either on the same or separate days for at least one day a week, and practiced such use for at least one month.
  • Willing to provide data on your vaping and smoking at baseline, 3, 6, 9 and 12 months.
  • Are not currently taking part in another conflicting study.

Thank you for your interest in this study. It is important that you understand what is involved before you consent to take part. There is information at the end of the information leaflet on how to contact the study organiser if you have any questions or concerns. Your participation is completely voluntary and will not affect any access to treatment or services that you may be currently receiving.

If you are interested in taking part please call: 0207 882 5747 (lines are open Monday-Friday, 9-5pm) Or click the link to email us: health-research@qmul.ac.uk

For more information and to apply to take part in this study click here!

 

 

 

UKCTAS comment on the latest tobacco control plan for England: “Towards a smoke-free generation”

The new tobacco control plan, ‘Towards a smoke free generation’ is a welcome restatement of the government’s commitment to reduce the prevalence, and hence the burden of death and disability caused, by smoking. The recognition that harm reduction strategies can play a key role in achieving these ambitions is applauded, and puts the UK at the forefront of global tobacco policy. However, the ambition to reduce adult smoking in England from 15.5% to 12% by 2022, representing as it does a reduction of 0.5 of a percentage point per year, is modest given that smoking prevalence has fallen by 2.9 percentage points in the last three years.

Recognising reducing smoking in pregnancy as a priority, and aiming to reduce prevalence in pregnancy to 6% or less, is welcome but will not be achieved without adequate resources, improved care pathways and addressing significant gaps in training for midwives and obstetricians. The commitment to make NHS inpatient mental health settings smoke-free by 2018 is long overdue, but it is disappointing that the same strong commitment is not extended to other NHS settings.

The ambition to make stop-smoking services more available is also welcome, but like the commitments to NHS settings and for pregnancy requires funding: when public health budgets are being slashed, how will local authorities afford to increase their smoking service provision?

What matters now is delivery: Action to achieve and exceed these ambitions is the next and crucial step

PDF of the Press Release

Vaping may help explain the record fall in UK smoking rates – Press Release with comments from UKCTAS Directors

UK smoking rates showed a record annual fall between 2015 and 2016 of 1.5 percentage points, based on new statistics released today [Link]. The prevalence of smoking among people aged 18 and above in 2016 was 15.8%, the lowest on record. This dramatic reduction is also the second largest annual fall in the last 40 years.

The UK is an international leader in smoking prevention policy, having introduced high tobacco taxes, a comprehensive advertising ban, prohibited smoking in public places, taken tobacco products out of sight in shops, establishing specialist stop-smoking services and a range of other measures. These policies have caused a sustained downward trend in adult smoking prevalence over the past two decades. Over the past five years, however, the rate of decline has increased substantially, falling by 4.4 percentage points, from 20.2%, since 2011.

Today’s new figures indicate UK smoking is falling faster than would be expected from conventional tobacco control approaches. While all the policies put in place will have made a difference, the most likely explanation for the recent rapid decline is the increasing use by smokers of electronic cigarettes as a substitute for tobacco. Data released by ASH last month estimated that there are now 1.5m people in the UK who used to smoke but now instead use electronic cigarettes.

Professor John Britton said:
“Electronic cigarettes were patented in 2004 but we began to see their use in the UK from around 2010. Since then the proportion of smokers using them has risen steadily. They have rapidly become the most popular aid to stopping smoking, and are now used in more than one third of quit attempts. At first we were unsure what their impact on smoking rates would be, but today’s figures suggest that alongside established tobacco control policies, they may have significantly accelerated the downward trend in smoking”

“Overall these findings vindicate UK policy on vaping: and that doing more to encourage more smokers to make the switch could generate huge benefits in public health: especially among those groups in society where smoking remains common.”

Professor Ann McNeill said:
“Since the millennium the UK has implemented a comprehensive tobacco control strategy to encourage and support smokers to stop and to deter young people from taking up smoking. This strategy included encouraging smokers to switch from deadly cigarettes to less harmful forms of nicotine including electronic cigarettes. It is really important that the new government continues this comprehensive approach and publishes its new Tobacco Control Plan as soon as possible, particularly given the need to tackle inequalities in smoking rates across society. In times of austerity, tobacco control is a good investment, as it benefits not just smokers and their families, but services like the NHS which bear the enormous costs of treating smoking-related illnesses”

Professor Linda Bauld added:
“The UK has taken a liberal approach to vaping, supporting the use of these consumer products for smokers who choose to use them. This has been controversial, and other countries have taken a much more restrictive approach. These new prevalence figures for adults, alongside steady declines in youth smoking uptake, suggest that electronic cigarettes may turn out to be a game changer for tobacco control. However, we know that many smokers are still wary of these products and think they are as harmful as tobacco. That needs to change if the positive trend we see from today’s figures is to be maintained.”

• Adult smoking habits in the UK: 2016 – Released 15 June 2017 External Link

• Smoking statistics in England – 15 June 2017 – Latest smoking compendium report signposting to all the up-to-date smoking data. External Link

 

Download the PDF version of this Press Release

 

New evidence finds standardised cigarette packaging may reduce the number of people who smoke as UK legislation bans the use of branding on all cigarette packets from May 2017.

A Cochrane Review published today finds standardised tobacco packaging may lead to a reduction in smoking prevalence and reduces the appeal of tobacco.

According to the World Health Organisation, tobacco use kills more people worldwide than any other preventable cause of death. Global health experts believe the best way to reduce tobacco use is by stopping people starting to use tobacco and encouraging and helping existing users to stop.

plain-packs-620-x-348-heroThe introduction of standardised (or ‘plain’) packaging was recommended by the World Health Organisation, Framework Convention on Tobacco Control (WHO FCTC) guidelines. This recommendation was based on evidence around tobacco promotion in general and studies which examined the impact of changes in packaging on knowledge, attitudes, beliefs and behaviour. Standardised tobacco packaging places restrictions on the appearance of tobacco packs so that there is a uniform colour (and in some cases shape) with no logos or branding apart from health warnings and other government-mandated information, and the brand name appears in a prescribed uniform font, colour and size.

From next month, UK legislation on standardised packaging for all tobacco packs comes into full effect.

Australia was the first country in the world to implement standardised packaging of tobacco products.  The laws, which took full effect there in December 2012, also required enlarged pictorial health warnings.

A team of Cochrane researchers from the UK and Canada have summarised results from studies that examine the impact of standardised packaging on tobacco attitudes and behaviour. They have today published their findings in the Cochrane Library.

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Healthier central England or North–South divide? Analysis of national survey data on smoking and high-risk drinking

In England, around 20% of the population are smokers and 13% drink excessively. These behaviours are leading risk factors for several non-communicable diseases, including cancer, diabetes and chronic respiratory and cardiovascular conditions. It is estimated that around 8000 deaths/year are alcohol-related and 80 000 deaths of adults aged 35 and over are attributed to smoking annually. The prevalence and adverse effects of high-risk drinking and tobacco use are not equally distributed across the country, with large regional variations.

A North–South divide exists for smoking, with higher rates of tobacco use, smoking-related deaths and smoking-related harm in northern regions. 

In contrast, excessive alcohol consumption tends to be lowest in central and eastern regions, while an East versus West divide is seen in the prevalence of alcohol dependency and alcohol sales. These regional variations in consumption do not always map onto experienced harm, a phenomenon known as the Alcohol Harm Paradox. In 2014, alcohol-related death rates were significantly higher among regions in the north of England compared with those in the south.

Objectives: This paper compares patterns of smoking and high-risk alcohol use across regions in England, and assesses the impact on these of adjusting for sociodemographic characteristics.

Design: Population survey of 53 922 adults in England aged 16+ taking part in the Alcohol and Smoking Toolkit Studies.

Measures: Participants answered questions regarding their socioeconomic status (SES), gender, age, ethnicity, Government Office Region, smoking status and completed the Alcohol Use Disorders Identification Test (AUDIT). High-risk drinkers were defined as those with a score of 8 or more (7 or more for women) on the AUDIT.

Results: In unadjusted analyses, relative to the South West, those in the North of England were more likely to smoke, while those from the East of England, South East and London were less likely. After adjustment for sociodemographics, smoking prevalence was no higher in North East (RR 0.97, p>0.05), North West (RR 0.98, p>0.05) or Yorkshire and the Humber (RR 1.03, p>0.05) but was less common in the East and West Midlands (RR 0.86, p<0.001; RR 0.91, p<0.05), East of England (RR 0.86, p<0.001), South East (RR 0.92, p<0.05) and London (RR 0.85, p<0.001). High-risk drinking was more common in the North but was less common in the Midlands, London and East of England. Adjustment for sociodemographics had little effect. There was a higher prevalence in the North East (RR 1.67, p<0.001), North West (RR 1.42, p<0.001) and Yorkshire and the Humber (RR 1.35, p<0.001); lower prevalence in the East Midlands (RR 0.69, p<0.001), West Midlands (RR 0.77, p<0.001), East of England (RR 0.72, p<0.001) and London (RR 0.71, p<0.001); and a similar prevalence in the South East (RR 1.10, p>0.05)

Figure 2Figure 2: Association between Government Office Region and high-risk drinking: (A) unadjusted;
(B) adjusted for gender, age, ethnicity and socioeconomic status (reference region: South West). Note: this shows the relative risk difference for each region relative to the South West (dotted reference region). Increasing red tones reflect increasingly higher significant risk and increasing blue tones reflect increasingly lower significant risk. Regions shaded white have a similar risk to the South West. Online supplementary figure S9 labels the Government Office Regions in England.
Expand Image – More diagrams in the main report

Conclusions: In adjusted analyses, smoking and high-risk drinking appear less common in ‘central England’ than in the rest of the country. Regional differences in smoking, but not those in high-risk drinking, appear to be explained to some extent by sociodemographic disparities.

Strengths and limitations of this study

  • Used a representative survey about smoking and drinking conducted on a large sample of the adult population in England.

  • Based on the most up-to-date information in England on regional differences in smoking and high-risk drinking accounting for disparities in gender, socioeconomic status (SES), ethnicity and age.

  • Respondents may have underestimated or failed to report their drinking and smoking.

  • Patterns of smoking and alcohol use were only available at the Government Office Region level, whereas important variation may occur at a more micro-geographical level.

bmj

Copyright information:
Published by the BMJ Publishing Group Limited.

 

Read the full report here!

MAJOR NEW REPORT  – UK HOSPITALS FAIL TO MEET NATIONAL STANDARDS IN EITHER HELPING PATIENTS QUIT SMOKING OR PROVIDING ‘SMOKE-FREE ENVIRONMENTS’

 

According to a major new report launched today (7/12/16) by the British Thoracic Society (BTS), NHS hospitals across UK are falling ‘woefully short’ of national standards on helping patients to quit smoking and enforcing smoke-free premises.

Experts f1-mediumpresenting the findings at the British Thoracic Society (BTS) Winter Meeting, will state that many NHS hospitals are missing out on a ‘golden opportunity’ to provide what is often the most effective front-line treatment for smoking patients who are sick  –  support and medication to help them quit tobacco.

The BTS Report ‘Smoking cessation: policy and practice in NHS hospitals’ is
unique in its scope and size; reviewing the smoking cessation & smoke-free policies and practices of 146 hospitals across UK between April and May 2016 – including the analysis of 14,750 patient records.

The main findings of the report are as follows:

  • Over 7 in 10 (72%) hospital patients who smoked were not asked if they’d like to stop
  • Only 1 in 13 (7.7%) hospital patients who smoked were referred for hospital-based or community treatment for their tobacco addiction
  • Over 1 in 4 (27%) hospital patients were not even asked if they smoke
  • Only 1 in 10 hospitals completely enforce their fully smoke-free premises. Rates of enforcement were even lower for hospitals which provided areas where smoking was allowed. The report highlights the importance of a smoke-free NHS – to trigger and support quit smoking attempts for patients and reduce second hand smoke exposure for children, staff and the public
  • Provision of nicotine replacement therapies and other smoking cessation treatments were ‘poor’ in hospital pharmacy formularies
  • Only 26% of hospitals had an identified consultant ‘lead’ overseeing their smoke-free and smoking cessation plans
  • 50% of frontline healthcare staff in hospitals were not offered training in smoking cessation

In the study, 25% of hospital patients were recorded as being ‘current smokers’ – which is higher than rates in the general adult population (19%)   Other studies have shown that approximately 1.1 million smokers are admitted to NHS hospitals a year.

The Society is using the report findings to call for all hospitals to deliver NICE Guidelines in this area (PH48) and that national regulators such as the Care Quality Commission (CQC) hold Hospital Boards accountable for the delivery of smoke-free and smoking cessation hospital policies.

The report also highlights a number of key activities that all NHS hospitals should deliver to help more of their patients quit smoking:

  1. Offer a prescription for Nicotine Replacement Therapy to all patients who smoke to help them cope with their tobacco dependence whilst in hospital
  1. Refer all patients who smoke in hospital to specialised stop smoking support services to explore the option of quitting smoking. Patients can opt out if they like – but the NHS should try to offer the most effective treatment and support whatever the illness – and with many smoking-related conditions such as chronic obstructive pulmonary disease (COPD), support and medication to help people quit smoking are the best front line treatments
  1. Employ an appropriately skilled senior clinician within the hospital to oversee, drive forward, and be accountable for the hospital’s smoking cessation service
  1. Employ smoking cessation practitioners in every hospital – this was recommended by NICE in 2013 but the report shows patchy delivery across the country
  1. Hospital Board involvement in delivering plans is key. Delivering smoke-free hospital grounds – as part of a wider smoking cessation policy – requires Hospital Boards to work together including the chief executive, director of human resources, director of facilities and the medical and nursing directors – in partnership with the ‘smoking cessation lead’ at the hospital

The Society is also encouraging more health professionals to become BTS ‘Stop Smoking Champions’ in their hospital. There are over 160 at present and they deliver a range of vital activities to champion stop smoking service provision.

For further information, contact stopsmokingchampions@brit-thoracic.org.uk or to see a video about the initiative go to: https://www.brit-thoracic.org.uk/standards-of-care/quality-improvement/smoking-cessation/bts-stop-smoking-champions/

Dr Sanjay Agrawal, Consultant Lung Specialist & Chair of the British Thoracic Society’s Tobacco Group, who led the audit said:

“Our report shows that many NHS hospitals are woefully failing to meet national guidance on delivering smoking cessation services and smoke-free premises. This is a dangerous situation that is costing the country dear in both health and economic terms. We must do better. Critically, hospitals are missing out on a golden opportunity to help supply often THE most effective treatment for illnesses that smokers are admitted with – support and treatment for their tobacco dependence.  If patients in other disease areas were not offered, by default, the most effective way to treat their condition – there would probably be an uproar. Nevertheless, this happens all too frequently with people with smoking-related illnesses. Many hospital boards need to sort out their leadership, plans and resources on this issue – so they can deliver some simple but life-changing steps: identify patients who smoke, ask them if they’d like to quit – and give effective treatment and support to help them stop.”

Dr Lisa Davies, Consultant Respiratory Physician at Aintree University Hospital and Chair of the British Thoracic Society Board, said:

“Being admitted to hospital should be a real window of opportunity for smokers to quit – given that smoking should be prohibited on the premises, tobacco use may be linked to their health condition, and expert stop smoking advice and therapies are potentially ‘on tap.’ This report shows, however, that we need to fund, plan and deliver smoking cessation work in hospitals far better – so we can fully deliver on this opportunity for our patients.

At a wider level, there is a real fight going on for the future of stop smoking support services in this country.  Many local authorities, facing overall budget reductions, have cut funding for community-based stop smoking services – meaning that people who need support may have nowhere to go.

The NHS must urgently work together, alongside local authorities, to plan and fund these vital services – to ensure no-one who needs treatment and support to stop smoking falls through the net.”

British Thoracic Society – UK hospitals fail to meet national standards in helping patients to quit smoking

British Thoracic Society, Smoking Cessation Audit Report:

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External news sources:

AOL – Hospitals ‘woefully failing’ to crack down on smoking

The Guardian – A third of children hospitalised with asthma ‘exposed to cigarette smoke’

Birmingham Mail – Number of patients forced to wait for hospital bed ‘rockets in five years’

NHE – All STPs urged to help patients quit smoking

The BMJ – NHS hospitals must help patients quit smoking, says British Thoracic Society