Smoking: support and treatment (all patients)

Indicator

The percentage of patients aged 15 years and over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months.

Introduction

This report provides a high-level cost impact assessment for one indicator relating to support and treatment for smoking cessation in the QOF smoking domain for inclusion on the 2012/13 NICE menu for QOF. The intent of this indicator is to add to the 2011/12 QOF organisational indicator Records 23 which incentivises a record of smoking status in people aged over 15. The proposed indicator would require all people recorded as a smoker to have a record of an offer of support and treatment.

Cost implication

Patient numbers affected

2011/12 QOF indicator Records 23 provides a register of people over the age of 15 years who have their smoking status recorded in the previous 2 years. 2009/10 National level QOF results for this indicator state 38.5 million people have their smoking status recorded.

QOF pilot data collected from a representative sample of GP practices in England, Scotland, Wales and Northern Ireland suggest the prevalence of ‘current smokers’ is approximately 19%. Estimates from the NHS Information Centre suggest the national prevalence of smoking in 2008 was 21% (NHS Information Centre, 2010a).

Using 21% as the estimated prevalence of smoking, and applying this to the number people with a record of a smoking status under QOF indicator Records 23, suggests the number of people eligible for an offer of support and treatment would be 8.1 million annually. However, taking into consideration the number of people that want to quit (43% [West 2008]), the estimated uptake of smoking cessation interventions and current levels of provision of smoking cessation services nationally (92% [NICE 2010]), the estimated number of people requiring an offer of support and treatment is 256,866.

Current care

NHS Stop Smoking Services are widely available. QOF pilot data suggests that 31% of people aged 15 years and over had been offered support and treatment by an NHS Stop Smoking advisor in the preceding 15 months. Data also suggested that most practices preferred to offer inhouse smoking cessation support i.e. and had NHS Stop Smoking accredited staff to support this.

The 2009/10 national QOF achievement data for the indictor Smoking 4, which incentivises the provision of advice or referral to a specialist service for people who smoke and also have a comorbidity, indicates a 92.8% achievement level (NHS Information Centre, 2010a). This equates to about 1.8 million people, or 25% of those people that would be eligible for an offer of support and treatment under the proposed indicator IND99. The provision of literature and an offer of therapy is also incentivised in all people that smoke in the QOF organisational domain indicator, Information 5.

The 2010 NICE implementation uptake report on smoking cessation drugs states that, in 2008/09, 91.8% patients receiving a smoking cessation drug were also receiving smoking cessation advice. This is assumed to be the baseline level of achievement.

Proposed care

Indicator IND99 incentivises an offer of support and treatment for current smokers every 2 years. For the purposes of this indicator an offer of support and treatment means offering referral or self referral to a local NHS stop smoking adviser (who might be a member of the practice team) plus pharmacotherapy.

The QOF guidance supporting this indicator states that the most effective method of stopping smoking is by using a combination of behavioural support (one-to-one or group) and pharmacotherapy. The costing report for NICE public health guidance on smoking cessation (NICE 2008) assumes that people who set a quit date and opt for group treatment attend an average of eight group sessions, whereas people who are offered individual behavioural counselling attend an average of six sessions.

The QOF guidance supporting this indicator also states that Pharmacotherapy alone is considered ‘good practice’ but with the addition of behavioural support from a trained smoking cessation advisor, this is considered ‘best practice’.

Resource impact

This indicator is not intended to identify additional smokers, and a record of smoking status is currently incentivised in a number of other QOF indicators.

Access to NHS Stop Smoking Services is widely available and most practices will choose whether to refer externally to these or self refer to an NHS Stop Smoking accredited member of the practice team.

Statistics on the NHS Stop Smoking Services in England estimate that the cost per person quitting smoking in 2009/10 was £224 (NHS Information Centre, 2010b). This does not include expenditure on pharmacotherapy. The estimated numbers of additional referrals into NHS Stop Smoking Services and associated costs are outlined below.

Table 1 Estimated annual cost of delivering NHS Stop Smoking Services

Detail	Units
People with a record of a smoking status in the past 27 months	38,543,541
% of 'current smokers' nationally	21%
People eligible for an offer of support and treatment	8,094,144
% of people wanting to quit	43%
People wanting to quit	3,480,482
Potential uptake	90%
People wanting an offer of support and treatment	3,132,434
Current baseline	92%
People currently being offered support and treatment	2,875,574
People not currently being offered support and treatment	256,860
Cost of a referral to smoking cessation services	£224
Estimated annual cost of delivery	£57,536,540
Estimated cost of delivery every 27 months	£28,768,270

Data from the 2009/10 NHS Stop Smoking Services in England suggests that, of those people who set a quit date, 65% received nicotine replacement therapy (NRT), 23% varenicline (Champix), 1% bupropion, and 1% both NRT and varenicline (5% of people did not receive any pharmacotherapy, and in 4% the treatment option was not known). (NHS Information Centre, 2010b.)

NRT and varenicline are prescribed for a maximum period of 12 weeks and bupropion for 9 weeks.

The estimated costs of treatment using pharmacotherapy are based on prices obtained from the British National Formulary 61 and outlined below.

Table 2: Estimated annual costs of pharmacotherapy

Detail	Units
No. of people requiring pharmacotherapy	256,860
Cost of NRT	£69.16
% receiving NRT	65%
People requiring NRT	167,318
Estimated annual cost of NRT	£5,785,860
Cost of bupropion (Zyban)	£79.70
% receiving bupropion (Zyban)	1%
People requiring bupropion (Zyban)	3,224
Estimated annual cost of bupropion (Zyban)	£128,486
Cost of varenicline (Champix)	£163.80
% receiving varenicline (Champix)	23%
People requiring varenicline (Champix)	59,466
Estimated annual cost of varenicline (Champix)	£4,870,301
Cost of NRT and varenicline (Champix)	£232.96
% receiving NRT and varenicline (Champix)	1%
People requiring NRT and varenicline (Champix)	2,720
Estimated annual cost of NRT and varenicline (Champix)	£316,830
Total annual cost of pharmacotherapy	£11,101,477

Sensitivity analysis

Estimates of cost have been for varying uptake levels from 50% up to a maximum of 100%.

Table 3: Estimated annual costs of delivering NHS Stop Smoking Services based on various levels of uptake

50%	60%	70%	80%	90%	100%
£15,982,372	£19,178,847	£22,375,321	£25,571,796	£28,768,270	£31,964,744

Table 4: Estimated annual costs of pharmacotherapy based on various levels of uptake

50%	60%	70%	80%	90%	100%
£6,167,487	£7,400,985	£8,634,482	£9,867,980	£11,101,477	£12,334,975

Potential savings

An estimated 112,000 people die due to smoking-related causes annually (Peto et al. 2006). These deaths are caused by respiratory conditions, cancers and circulatory and gastrointestinal diseases (Royal College of Physicians of London 2000).

The costing report for NICE public health guidance 1 (‘Brief interventions and referral for smoking cessation in primary care and other settings’) states that the 1998 annual estimates of the cost of smoking on the NHS of £1.5 billion are expected to be much higher today, and that helping people who smoke to stop is one of the most cost-effective interventions a health service can deliver (NICE 2006).

The health economic models supporting NICE public health guidance 1 (NICE 2006) and NICE technology appraisal 123 (‘Varenicline for smoking cessation’ [NICE 2007]) found smoking cessation interventions to be cost effective, and smoking cessation treatment options, both pharmacological and advisory, to be highly cost effective in terms of life-years gained.

Implementation of these indicators is therefore likely to result in financial savings to the wider NHS through a reduction in ill health associated with smoking. 

Conclusions

The availability and ease of access of NHS Stop Smoking Services nationally means that there are already high levels of support and treatment for people that smoke. The 2010 NICE implementation uptake report on smoking cessation drugs states that a high proportion of patients are already offered a smoking cessation programme, with 91.8% of patients receiving a smoking cessation drug also receiving advice (NICE 2010).

The annual cost of new referrals into NHS Stop Smoking Services based on a potential uptake of 90% is estimated to be £28.7 million. Based on 2009/10 NHS Stop Smoking Services data, the cost of pharmacotherapy for this population is estimated to be £11.1 million (NHS Information Centre 2010a). The overall annual cost of delivery of this indicator is therefore estimated at £39.8 million.

It is important to note that the cost per referral for smoking cessation advice will vary between different services, as will the degree to which one-to-one counselling is offered compared with group therapy.

The cost of smoking to the NHS and the morbidity and mortality attached to smoking is considerable. Smoking cessation treatment options, both pharmacological and advisory, are highly cost effective in terms of life-years gained. Therefore, implementation of these indicators is likely to result in financial savings to the wider NHS.

Related QOF indicators

National level results for 2009/10 for the current QOF indicator (NHS Information Centre 2010)

Current QOF indicator	Numerator	Denominator	Underlying achievement
SMOKING 4. The percentage of patients with any or any combination of the following conditions: CHD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months	1,825,028	1,966,130	92.8%
Records 23: The percentage of patients aged over 15 years whose notes record smoking status in the past 27 months	38,543,541	45,568,208	89.4%
Information 5: The practice supports smokers in stopping smoking by a strategy which includes providing literature and offering appropriate therapy	-	-	98.6%

References

NHS Information Centre (2010) QOF 2009/10 results: England level QOF tables 2009/10 – clinical tables 2009/10.

NICE (2008) Smoking cessation services: costing report.

British National Formulary 61 (2011). London: BMJ Group and RPS Publishing.

NICE (2006) Brief interventions and referral for smoking cessation: costing report. 

Peto R, Lopez JD, Boreham J et al. (2006) Mortality from smoking in developed countries,1950–2000 (2nd edition). Oxford: Oxford University Press

Royal College of Physicians of London (2000) Nicotine addiction in Britain. London: Royal College of Physicians of London

NICE (2007) Varenicline for smoking cessation. NICE technology appraisal 123. 

NHS Information Centre (2010) Statistics on NHS Stop Smoking Services: England 2009/10 results - Statistics on NHS Stop Smoking Services tables 2009/10. 

West R (2008) Key performance indicators: findings from the Smoking Toolkit Study. Smoking in England.

NICE (2010) Implementation uptake report: Smoking cessation drugs.