Commissioning a smoking cessation service for people having elective surgery

NICE public health guidance PH10 on smoking cessation services recommends that patients referred for elective surgery should be encouraged to stop smoking before an operation. The guidance outlines several interventions and states that effective smoking cessation aids and services are highly cost effective. Following surgery, smoking contributes to lower survival rates, delayed wound healing and postoperative respiratory complications. However, a quarter of patients undergoing surgery continue to smoke up to, and after, surgery. There is also evidence of variation in advice on smoking cessation given to patients before elective surgery^[1].

NICE public health guidance PH1 on brief interventions and referral for smoking cessation states that smoking cessation advice and support should be available in community, primary and secondary care settings for everyone who smokes. The hospital setting is an opportunity for all health professionals to offer people brief advice, support and referral to the NHS Stop Smoking Service. NICE public health guidance PH6 on behaviour change notes that significant events or transition points in people's lives present an important opportunity for intervening at some or all of the levels [individual, household, community or population], because it is then that people often review their own behaviour and contact services. A hospital admission may boost a person's receptivity to smoking cessation interventions and increase their motivation to stop smoking^[2].

Smoking remains the main cause of preventable morbidity and premature death in England, leading to an estimated annual average of 86,500 deaths between 1998 and 2002. Smoking is estimated to cost the NHS £1.5 billion a year. This estimate does not include other costs to government such as payment of sickness or invalidity benefits. Nor does it include the costs to industry or to individuals who smoke. Smoking is the primary reason for the gap in healthy life expectancy between rich and poor. An evaluation of NHS stop smoking services found they made a modest contribution to reducing inequalities in smoking prevalence^[3].

The Department of Health's Improvement, expansion and reform: priority and planning framework 2003-2006 requires a reduction in adult smoking rates (from 26% in 2002) to 21% or less by 2010, with a reduction in prevalence among routine and manual groups (from 31% in 2002) to 26% or less by 2010. More recently the Department of Health published vital signs which require the NHS to return local data including quit rates.

Benefits

The potential benefits of robustly commissioning an effective smoking cessation service for people having elective surgery include:

• increasing the number of people who stop smoking for their operation
• increasing the number of people who maintain their smoke-free status postoperatively
• increasing the number of people who stop smoking as a result of the enforced abstinence during their elective stay
• improving postoperative recovery
• reducing hospital length of stay
• improving clinical outcomes by reducing smoking-related ailments and postoperative complications, for example in wound healing
• reducing inequalities by increasing opportunities to access stop smoking support, particularly for hard-to-reach groups
• offering the opportunity for a personalised, tailored intervention
• better value for money: efficient commissioning may give opportunities for clinicians to undertake local service redesign to meet local requirements in innovative ways
• supporting local policies for NHS smoke-free premises.

Key clinical issues

The key clinical issues in providing an effective smoking cessation service for people having elective surgery are:

• accurately identifying all people who smoke and who wish to give up smoking
• ensuring that appropriate referral pathways are in place for those interested in receiving further support
• providing evidence-based smoking cessation support and effective prescribing in line with NICE public health guidance PH10 on smoking cessation services and NICE technology appraisal TA123 on varenicline for smoking cessation
• providing a discharge plan to co-ordinate ongoing smoking cessation support and prescribing if appropriate
• providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning a smoking cessation service for people having elective surgery include:

• World class commissioning.
• The NHS Cancer plan: a plan for investment, a plan for reform sets national and local targets for the reduction of smoking rates and the health inequalities gap by 2010.
• High quality care for all: NHS next stage review final report by Lord Darzi sets out a vision for the NHS to deliver personalised services.
• Tackling health inequalities: a programme for action.
• The Health Act 2006 legislated for smoke-free premises and has direct implications for people who smoke during hospital admission.
• The NHS in England: the operating framework for 2009/10.
• National service frameworks for: coronary heart disease, diabetes, long-term conditions.
• Delivering the 18 week patient treatment pathway.
• The Care closer to home initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
• Commissioning framework for health and well-being.
• Choice matters: increasing choice improves patients´ experiences.
• The Expert patients programme.
• A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with ‘Standards for better health'.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.

References

1. Theadom A, Cropley M (2006) Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review. Tobacco Control 15: 352-8.

2. Rigotti NA, Munafo MR, Stead LF (2007) Interventions for smoking cessation in hospitalised patients.Cochrane database of systematic reviews (3).

3. Bauld L, Judge K, Platt S (2007) Assessing the impact of smoking cessation services on reducing health inequalities in England: observational study. Tobacco Control 16: 400-4.