Stop Smoking Wales. Annual Report

Transcription

1 Stop Smoking Wales Annual Report

2 Authors: Stop Smoking Wales Editorial Group Date: 13/07/2012 Version: 1e Status: Final Relevant Previous Documents: Welsh Government Programme Level Agreement Publication/Distribution when finalised: Publication in Public Health Wales Document Database (Health Improvement) Link from Public Health Wales e-bulletin Link from Stakeholder e-newsletter Stop Smoking Wales website Other distribution/publication (e.g. Directors of Public Health) Public Health Wales is an NHS organisation providing professionally independent public health advice and services to protect and improve the health and wellbeing of the population of Wales. 2

3 Further copies of this Annual Report are available in hard copy from: Stop Smoking Wales Public Health Wales Block B, Mamhilad House, Mamhilad Park Estate, PONTYPOOL, NP4 0YP Download from: Public Health Wales NHS Trust Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context. Acknowledgement to Public Health Wales to be stated. Copyright in the typographical arrangement, design and layout belongs to Public Health Wales. 3

4 Contents 1 Foreword Executive summary Smoking and health in Wales Operational service delivery Activity and outcomes of behavioural support programme Strategic partnership and direction Training Primary care engagement Partnerships with community pharmacy Pre-operative smoking cessation Services for vulnerable groups Workplace health Conclusion and acknowledgements...68 Appendices Appendix 1: Calculation of service outcomes Appendix 2: Service outcome data Appendix 3: Run charts (maternity contacts) Appendix 4: Run charts (pre-operative contacts) Appendix 5: Website analysis References

5 1. Foreword Smoking remains the leading cause of preventable death and disease and is one of the main causes of health inequities in Wales. The key priority in the strategic framework for improving public health, Our Healthy Future, is the need to reduce smoking and subsequent harm. During 2011/12 Stop Smoking Wales has delivered National Health Service (NHS) specialist smoking cessation services across Wales in local, accessible venues helping thousands of smokers to stop. This is a time of great potential for reducing smoking rates in Wales. The Welsh Government Tobacco Control Action plan produced this year firmly embeds smoking cessation services in the plan. The direction is clear and the national plan is to eradicate tobacco harm in Wales and reduce smoking rates across the population. Ambitious targets are proposed to reduce smoking across Wales, from the current average of 23 per cent regular smokers in the adult population to less than 16 per cent by This report describes the activity and outcomes of Stop Smoking Wales in supporting adult smokers in Wales to stop smoking during 2011/12. It demonstrates the progress made in specific priority areas in maternity services with pregnant women who smoke and in pre-operative patients who smoke and who are waiting for surgery. These activities have made and continue to make a major contribution to reducing overall smoking prevalence rates in Wales. During , training has been delivered to a range of health care and other professionals to support and increase brief interventions to encourage more smokers who want to stop to access services. This year there is a change to the data activity and outcomes reporting methodology, (see appendix 1 for further information). The service maintains the delivery of a standard smoking cessation intervention tailored to need, so that smokers who want to stop can expect the same quality wherever they are in Wales. 5

6 Stop Smoking Wales has undergone a management restructure in Since then, a number of key posts within Stop Smoking Wales have not been occupied in recent months. This has in turn impacted on senior management capacity within the service. Our vision is to fill these posts to ensure that planned development work is implemented in In our intention is to focus our resources on specific priorities. In line with the concept of proportionate universalism, we will target our resources towards: Areas of high prevalence Brief intervention training of midwives, pre-operative services, health visitors and pharmacists in deprived areas Supporting the development of a bid for more resources to help pregnant women to quit smoking Use of technology to reach and deliver generic services This national service is delivered in partnership with other organisations, services and we rely heavily on the support and commitment of our loyal staff and partners. I would like to take this opportunity to thank all the staff and our colleagues whom we have worked with (including Health Boards, primary care and community care, local authorities and the voluntary sector) for their support during the last twelve months. Stop Smoking Wales looks forward to the next year working with our partners to increase access across Wales to high quality smoking cessation services, in order to reduce smoking rates and improve the health of the population of Wales. Dr Hugo van Woerden, Director of Health and Health Care Improvement 6

7 2. Executive summary Stop Smoking Wales is now well established as the National Health Service (NHS) specialist smoking cessation service covering the whole of Wales. 2011/12 has been another successful year for the service in supporting people to stop smoking. The service provides high quality smoking cessation to local populations across Wales and this year 15,781 people who wanted to access the behavioural support programme were scheduled an appointment. This year has also seen a high number of self reported quitters since the ban on smoking in public places which was introduced on 2 April Smoking Cessation services sit within a wider context of tobacco control and Stop Smoking Wales has made a valuable contribution to developing tobacco control plans at a national and local level. The key service outcomes for 2011/12 achieved in excess of the agreed success rates for self-reported and carbon monoxide validated quits at four weeks and include the following results: 1908 groups and 2229 individual 1:1 appointments were scheduled in 2011/12 equating to of behavioural support session hours. 15,781 people were scheduled an appointment with Stop Smoking Wales in 2011/12 10,200 smokers attended Stop Smoking Wales behavioural Support programme and 7,061 became treated smokers. This represents 64.6 per cent of people who contacted Stop Smoking Wales attended and 44.7 per cent becoming treated smokers. 4,043 of the treated smokers self reported that they had quit smoking at four-week follow up. This represents 57.3 per cent of treated smokers. 7

8 2,887 clients who participated in the six-week behavioural support programme and attended the final treatment session were validated by carbon monoxide (CO) monitoring and confirmed as not smoking. This represents 40.9 per cent of treated smokers. Of the 4,510 clients who had self reported abstinence from smoking at four weeks between 1 April 2010 and 31 March 2011 and were therefore eligible to be followed-up at 52-weeks post quit date, 2, 919 were successfully contacted. Of those eligible to be followed up, 1,370 (30.4 per cent) clients reported that they were still not smoking at 52-weeks Since the implementation of the new telephone system in August 2011 a total of 27,876 calls were received to the Stop Smoking Wales free-phone telephone number between 1 September 11 to 31 March In 2011/12 Stop Smoking Wales provided the accredited smoking cessation brief intervention training course. 76 brief intervention training courses were delivered to over 692 healthcare and community professionals Brief intervention for smoking cessation e-learning module was launched in January E-learning modules are available and have been promoted widely since January 2012, which will increase and widen access to knowledge and skills in smoking cessation across Wales As part of the five year strategic framework for NHS Wales, National Prevention and Promotion Programme, Stop Smoking Wales has supported smoking cessation implementation in NHS Wales across community, primary and secondary care settings with the aim to reduce demand on health services and to cut costs 8

9 Stop Smoking Wales has worked in partnership with Health Boards to target action across local populations to maximise the numbers of smokers accessing evidence based smoking cessation support within local tobacco control action plans Various promotional events across Wales in 2011/12 were supported by staff, of which 29 were No Smoking Day events In January 2012 the service new redesigned interactive website was launched. Since January 2012, 7,802 visits in total from 6,499 unique visitors were received A primary care engagement programme has been implemented, including systematic visits to GP practices, production of an educational resource and a pathway for patient care The service has worked closely with pharmacists in Health Boards and the community to support consistent approaches to smoking cessation across Wales. Level two pharmacy schemes have been supported and developed in several Health Board areas. Stop Smoking Wales has delivered training in brief intervention to pharmacy staff and to pre-registration and practising pharmacists under the Welsh Centre for Pharmacy Professional Education Programmes Service development in priority areas have continued to build smoking cessation pathways in maternity and pre-operative smoking cessation. Stop Smoking Wales continues to work closely with Health Boards to develop strong pathways into smoking cessation services and to consider the most effective routes for clients Stop Smoking Wales has developed guidance to assist employers to help employees to stop smoking within the overall policy of smoke 9

10 free workplaces. The guidance has been developed for incorporation into the Corporate Health Standard package. 41 Workplace based smoking cessation programmes were delivered during 2011/12 A Stop Smoking in Prisons Toolkit has been developed for use in the prison setting which follows Stop Smoking Wales service delivery model I m glad I attended Stop Smoking Wales. I met a nice advisor who took the course, also a few people who wanted to stop Smoking. Since I finished the course I haven t smoked. My age is 76. I ve been smoking for about 60 years, not heavy but regular. Female 77 years 10

11 Monmouthshire The Vale of Glamorgan Flintshire Bridgend Swansea Conwy Powys Carmarthenshire Pembrokeshire Ceredigion Cardif f Denbighshire Caerphilly Isle of Anglesey Gwynedd Newport Torf aen Neath Port Talbot Wrexham Merthyr Tydfil Rhondda Cynon Taf Blaenau Gwent 3. Smoking and health in Wales Tobacco is a preventable cause of early death in Wales and the world today (WHO, 2008). It is calculated that over 5,000 premature deaths are attributable to smoking related diseases each year in Wales (Public Health Wales Observatory, 2010). The current prevalence of smoking in the adult population in Wales is 23 per cent (Welsh Assembly Government, 2011). Furthermore, smoking rates range from two per cent to nine per cent difference in Local Authority populations which illustrates how smoking leads to inequalities. The graph below demonstrates the percentage of adults who are reported being a current smoker by Local Authority with 19 per cent in Monmouthshire being the lowest to 28 per cent in Blaenau Gwent being the highest. Figure 1: Percentage of Adult Smokers by Local Authority Age standardised per cent of adults who reported being a current smoker, by local authority, 2010 Produced by Public Health Wales Observatory using WHS 2010 (WG)

12 Smoking leads to significant health inequalities, evidence suggests that smoking is the primary reason for the gap in healthy life expectancy between the rich and poor (Welsh Assembly Government, 2011). Tobacco smoking has been estimated to cost the NHS in the UK 2.7 billion every year (Callum et al 2010). Specifically, the cost of tobacco smoking to NHS Wales was an estimated 386 million in 2007/08 which accounts for seven per cent of healthcare expenditure (Phillips and Bloodworth, 2009). Smoking also costs the wider UK economy an estimated 2.5 billion per annum for sick leave and lost productivity (McGuire et al, 2009). Smokers are more likely to be absent due to ill health, and for longer, than those who do not smoke (Boorman 2009). Smoking can be estimated to cost the smoker over 2,700 per year, based on smoking 20 cigarettes per day The potential health benefits of smoking cessation are significant. Stopping smoking reduces the future risk of tobacco related diseases, slows the progression of existing tobacco related disease, and improves life expectancy by an average of 10 years (Centers for Disease Control and Prevention, 2004). Group meeting is good motivation not to smoke. It may help to reduce the group meeting to monthly after the 6 weeks to continue motivation not to restart - especially when patches are withdrawn, i.e. NRT reduced to zero. Female 53 years 12

13 3.1 Strategic approach to tobacco control The Welsh Government Tobacco Control Action Plan has four main areas for action: 1. Promoting Leadership in Tobacco Control 2. Reducing the uptake of smoking in children 3. Reducing smoking prevalence levels 4. Reducing exposure to second-hand smoke (Welsh Assembly Government, 2011a) The Tobacco Control Action Plan for Wales was published in February It is a comprehensive framework that sets the direction in Wales for partnerships and collaboration to reduce tobacco harm in Wales. Smoking cessation services are firmly embedded in the agreed national plan with a clear direction for Stop Smoking Wales. It encourages sectors and organisations to work together to reduce smoking rates. A national target is proposed in the plan to reduce smoking across Wales from the current average of 23 per cent regular adult smokers in the population, to under 16 per cent by 2020 (Welsh Assembly Government, 2011a). These are very ambitious targets; however, it is one that has been achieved elsewhere, in the USA and Australia. The Strategic Framework for Public Health in Wales Our Healthy Future sets the direction for action to protect and improve health in Wales (Welsh Assembly Government, 2009b). Reducing smoking prevalence is one of the ten identified priorities in the strategic framework. A comprehensive approach to tobacco control is necessary to reduce smoking rates effectively. Smoking cessation is a significant component of this approach. However, it must be seen alongside other measures to reduce uptake and create environments that support tobacco free lifestyles and the de-normalization of cigarette smoking. 13

14 4. Operational Service delivery Public Health Wales provides specialist smoking cessation services for the people of Wales, on behalf of the Welsh Government through a Programme Level Agreement. Research has demonstrated that evidence based smoking cessation services are a highly cost-effective way of helping smokers to stop smoking (Brose et al, 2011) (West, McNeill and Raw, 2000). Furthermore, there is a large body of evidence regarding the effects of smoking cessation interventions in smokers. For individuals who seek help, a variety of methods have been shown to help stop smoking, which include individual advice and counselling, nicotine replacement therapy, antidepressants, smoking cessation courses, (Hughes 2004; Lancaster 2005; Silagy 2004; Stead 2005). In Wales, 27 per cent of adults have already stopped smoking i.e. exsmokers (Welsh Assembly Government, 2009). Out of those adults who still smoke, 70 per cent would like to give up, whilst 40 per cent state that they have tried to stop in the last year (Welsh Assembly Government, 2009). This is in line with the UK on the whole where approximately, two-thirds of smokers state that they want to stop smoking (ONS, 2010). This is an enormous potential for Stop Smoking Wales to assist in helping these smokers to stop and the support reduction of health inequalities. The National Institute for Health and Clinical Excellence (NICE) recommends that smoking cessation services should set realistic performance targets. That would include the number of clients using the service and the proportion that successfully quit smoking. It should reflect the demographic of the local population; aim to treat 5 percent of the population of people who smoke each year. Also aim for at least 35 per cent 4 week success rate. This figure should be based on all those who start treatment, with success defined as not having smoked in the third and fourth week following the quite date. It also needs to be 14

15 Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pem brokeshire Carm arthenshire Swansea Neath Port Talbot Bridgend The Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monm outhshire Newport Wales validated with carbon monoxide verification (The National Institute for Health and Clinical Excellence National, 2007). During Stop Smoking Wales treated 1.3 per cent of the smoking population across Wales, which ranged from 0.3 per cent in Gwynedd to 2.5 per cent in Neath Port Talbot and Merthyr Tydfil, (See appendix 2 for table). Figure 2: Percentage of smokers treated by Stop Smoking by smoking population Percentage of smokers treated by Stop Smoking Wales, Wales and local authorities, 1 April March 2012 Produced by Public Health Wales Observatory using Stop Smoking Wales data & MYE 2010(ONS) Percentage treated by SSW NICE target 5%

16 It is known that a combination of behavioural support from a trained smoking cessation advisor plus pharmacotherapy can increase a smoker s chance of stopping smoking by up to four times (Ferguson, et al., 2005). In addition, from NHS smoking cessation clinic data and controlled trials, it has become clear that if smokers receive support from a combination of smoking cessation clinics, with treatment in groups along with access to pharmacotherapy, they will be more likely to succeed than those smokers receiving treatment in primary care, one-to-one and single NRT (Brose et al, 2011). It is important that all smokers should have access to the most effective services (Croghan, 2011). Smokers who are motivated to stop smoking are the main target audience for Stop Smoking Wales services, based on established knowledge that cessation is more effective when individual reason and motive exists. Stop Smoking Wales service delivery has two core aims and are as follows: to provide an effective, evidence based behavioural support programme offering choice and access to smokers who want to give up smoking to train healthcare and community workers in brief intervention for smoking cessation at every opportunity to encourage contacts into the service 16

17 4.1 Intensive behavioural support programme Smokers can self refer themselves to the support programme when they are motivated to quit smoking. It is not necessary to be referred by a healthcare professional; nonetheless, health professionals may refer clients. The service operates a free-phone number ( ) where a booking to attend a session can be made by the smoker when it is convenient to them. Stop Smoking Wales delivers an evidence based intensive behavioural support programme for people who are motivated to stop smoking. The programme is based on the withdrawal oriented therapy model (Hajek, 1989) which focuses on key objectives: maintaining or enhancing motivation to stop smoking avoiding or minimising motivation to smoke preventing the desire to smoke turning into action (West, McNeill and Raw, 2000) The sessions are client centred, providing encouragement and support to stop smoking during the period that withdrawal symptoms are at their worst. Carbon monoxide (CO) monitoring is a requirement of high-quality practice in smoking cessation, where validation of smoking status is required at the four week post quit point. This is part of Stop Smoking Wales service delivery model and is offered to all clients. Measuring CO weekly is also a good motivational tool, where clients can observe their CO reading decrease in a relatively short time period on quitting smoking. When a person stops smoking, CO is eliminated from the body within approximately 24 hours (McEwen et al, 2006a). 17

18 Stop Smoking Wales programme is delivered by trained smoking cessation advisors, who work predominantly in the area of smoking cessation. Following attendance at an initial assessment session, smokers are encouraged to attend the next six consecutive weekly treatment sessions. The sessions are primarily delivered on a closed group principal basis; as this is the most effective and efficient method of delivery (Brunnhuber et al, 2007). Groups have been identified as more effective than individual treatments (McEwen et al., 2006a) and also have been found to produce higher success rates (McEwen et al., 2006b). Results from treatment delivery methods have shown that closed group provision is significantly more effective, with average success rates of 64% compared with 49% for one-to-one treatment (NHS Information Centre, 2009). However, one-to-one sessions are arranged when appropriate to accommodate specific needs of clients. The service model reflects the existing evidence base for smoking cessation. The programme includes: Week 1 Preparation to stop smoking. Agreeing a quit date by the following week and a CO validation Week 2 Weeks 3-5 Discussion on withdrawal symptoms, changing daily routines, to prevent the association with the habit of smoking and psychological dependence and a CO validation Mutual encouragement, natural competition and support, the benefits of quitting and sharing of experiences relating to quitting, such as coping strategies, and a CO validation Week 6 Relapse prevention techniques for the next 12 months high risk occasions for e.g. holidays, birthdays or significant events and also CO validation to determine smoking status (fourweek follow up) 18

19 4.2 Clinic locations, venues and scheduling Stop Smoking Wales offers clients a choice of where and when they access the community based service. Sessions are delivered in a range of local venues including primary care settings, secondary care settings, community health clinics, libraries, leisure centres, community halls and workplaces. The administrative staff, who work for Stop Smoking Wales are exceptionally skilled in the use of the database and are able to offer clients a choice of convenient appointments, with day and early evening sessions available. Stop Smoking Wales aims to provide an appointment within 4 weeks as stated in the Design for Life, (Welsh Assembly Government, 2005) however, work has been undertaken on the scheduling of sessions and endeavoured to reduce this to two weeks. At present, the average waiting time for an appointment is within 19 days across Wales, which varies from 14 days in Cwm Taff Health board to 22 days in Hywel Dda Health Board for 2011/12. Table 1: Average waiting times per Health Board area 1 April 2011 to 31 st March 2012 Health Board Average of number of waiting days Abertawe Bro Morgannwg University HB 21 Aneurin Bevan LHB 17 Betsi Cadwaladr University HB 20 Cardiff and Vale University HB 15 Cwm Taf HB 14 Hywel Dda HB 22 Powys University HB 17 Total 19 19

20 In 2011/12 Stop Smoking Wales scheduled 1908 stop smoking groups and 2229 individual 1:1 appointments in 359 locations across Wales. The combined scheduling of groups and 1:1 sessions equates to hours of behavioural support sessions delivered by advisors across Wales. The numbers of groups scheduled have reduced by 208 for the same period in 2010/11. The reduction in the number of groups is a result of recommendations of the demand and capacity review 2010/11. For example, the review highlighted inefficiencies in some group locations, such as, venue size limited numbers able to attend. Therefore, as an outcome of these findings locations were changed to larger capacity venues. The 359 venues that are used to facilitate the behavioural support sessions are strategically located on population, accessibility and service capacity. The map below (figure 3) highlights where current stop smoking venues are situated in relation to areas of deprivation. As a result of having this invaluable data provided by Public Health Wales Observatory, we are able to make adjustments and improvements to the current venues. Work on the current venues will be completed during , which will ensure venues are reaching the most disadvantaged areas in Wales. 20

21 Figure 3: Stop Smoking Wales Venues and Welsh Index of Multiple Deprivation fifths Source: SSW, WAG 21

22 5. Operational activity and outcomes of behavioural support programme The client journey is not normally completed until a minimum of twelve weeks from initial contact. Therefore there is a time lag in producing reports. However, the reporting methodology for this annual report and for future reports has been changed to ensure reports can be produced in a timely manner. In previous annual reports, the data methodology would have exclusively reported on the contacts to the service during the specific time period. These reports would have reflected the outcome of all contacts and activity during the specific time period. Data included in this and future reports will be as follows: Data will be captured on the contacts for the period 01 April 2011 to 31 March 2012 and will be broken down by Health Board, Local Authority area, gender, age and ethnicity. Data will then be captured on all clients that were scheduled to attend the behavioural support programme for the period 01 April 2011 to 31 March 2012 which will be broken down by Health Board, Local Authority area, gender, age and ethnicity, attending, followed up, self reported abstinent and CO validated abstinent at 4-weeks. Improving the quality and consistency of outcomes recording and reporting has been one of Stop Smoking Wales key priority areas in recent years. The service adopts nationally agreed standards in recording and reporting its outcomes, in line with other services across the UK. The Russell Standard (West, 2005) is widely accepted as the leading standard for calculating outcomes in smoking cessation services. The standard is composed of set criteria and these are used to define Stop Smoking Wales services outcomes for 2010/11. The criteria include; 22

23 Treated smoker Four-week quitter (self reported) Four-week quitter (carbon monoxide [CO]-verified) Lost to follow-up Further detail on the Russell standard is contained in Appendix 1. The service is proud of the fact that it has consistently adopted the Russell standards over recent years. 5.1 Contacts to Stop Smoking Wales The term contact is used with a specific technical meaning in the context of smoking cessation services. Contacts are defined as those accepting and having an appointment with an Advisor, furthermore this is the case with all smoking cessation services in the UK. The number of contacts from clients to Stop Smoking Wales between 1 April 2011 and 31 March 2012 was 15,781. The clients would then have been scheduled an appointment at their convenience, which may be outside of this period. For example, a client could contact the service on 23 March 2012 and be booked into an appointment on 23 April As is the case with all smoking Cessation Service in the UK, Stop Smoking Wales has an inherent variation and will see call volume peak during the month of January and decline during December. In previous years contacts have declined during summer months but for the last few years calls have been more consistent month on month with fluctuation of less than 0.1 per cent in some months. Government media campaigns or active promotional events such as No Smoking Day in March can also increase contacts to the service as can be illustrated in figure 4. 23

24 Figure 4: Month on month contacts from 1 April 2011 to 31 March Monthly contact data Monthly contact data Contacts per month 0 In 2011/12 analysis of the data demonstrates that there has been an increase in contacts to Hywel Dda Health Board with a significant increase in Betsi Cadwaladr University Health Board of 17.4 per cent. Data has shown a small decline in numbers per Aneurin Bevan Health Board, Cwm Taf Health Board, Abertawe Bro Morgannwg University Health Board, Powys Teaching Health Board and Cardiff and Vale University Health Board. Overall, there has been a decrease by 1.4 per cent on 2010/11 contacts. The constant support and encouragement meant a lot to me. All comments were positive. My advisor never said anything negative about anyone smoking and constantly told us how well we were doing. She was a lovely lady who did her job very well. Female 65 years 24

25 Table 2: Contact information for 1 April 2011 to 31 March 2012 by Health Board and Local Authority Health Board Area Betsi Cadwaladr University Health Board Powys Teaching Health Board Hywel Dda Health Board Aneurin Bevan Health Board Cwm Taf Health Board Abertawe Bro Morgannwg University Health Board Cardiff and Vale University Health Board Local Authority area No. of contacts Anglesey 240 Conwy 552 Denbighshire 441 Flintshire 1065 Gwynedd 157 Wrexham 374 Total 2,829 Powys 677 Total 677 Carmarthenshire 1453 Ceredigion 302 Pembrokeshire 695 Total 2,450 Blaenau Gwent 469 Caerphilly 770 Monmouthshire 220 Newport 585 Torfaen 495 Total 2,539 Merthyr Tydfil 507 Rhondda Cynon Taf 1045 Total 1,552 Bridgend 935 Neath Port Talbot 1584 Swansea 2242 Total 4,761 Cardiff 751 Vale of Glamorgan 222 Total 973 Wales Total 15,781 There are a number of pharmacy level two schemes operating across Wales which could possibly contribute to the variation in contacts per Health board, for example Abertawe Bro Morgannwg and Hywel Dda Health Boards which offer pharmacy scheme. 25

26 Public Health Wales Observatory analysed smoking prevalence estimates (Welsh Assembly Government, 2009a) and population data (Office for National Statistics, 2010) to enable the calculation of a crude rate of smokers contacting the service to illustrate the variation in referrals to the service across Wales. Figure 5 demonstrates that there was wide variation in referrals from Health Board areas across Wales with the lowest contact rate in Cardiff and Vale University Health Board 1.2 per cent, whilst the highest contact rate was within Abertawe Bro Morgannwg University Health Board 5.1 per cent. The service is working in partnership with stakeholders to better understand this variation in referrals to the service. Figure 5: Health Board contact rate by population 2011/12 Proportion (%) of estimated number of smokers contacting Stop Smoking Wales 1 April March 2012 Produced by Public Health Wales Observatory, using Stop Smoking Wales data, MYE 2010 (ONS), Welsh Health Survey (WG) 5.1 Wales = Cardiff and Vale UHB Betsi Cadwaladr UHB Aneurin Bevan HB Cwm Taf HB Powys Teaching HB Hywel Dda HB ABMU HB Excellent support. Good tips and ideas on how to change habits. Female 53 years 26

27 Number of clients The highest numbers of contacts in the reporting period were from females aged between 35 and 59 who accounted for 27.5 per cent of all contacts. The least contacts were received from males aged under 18 (0.9 per cent). Overall a higher proportion of contacts were females (57.1 per cent) compared to males (44.9 per cent). For both males and females the highest proportion of contacts were aged between 35 and 59 (49.2 per cent) and the lowest from those aged under 18 (2.1 per cent) (see Appendix 2 for full breakdown by age, gender and ethnicity). ASH Wales are setting up a new service to meet the needs of year olds, which will compliment Stop Smoking Wales. The largest proportion of contacts by ethnic group was from the White category (98.7 per cent). The least contacts were received from the Black category (0.1 per cent). 5.2 Comparison of activity and outcomes with previous years Since 2004/05, there has been an increase in the number of contacts to the service which is currently at 49.2 per cent for 2011/12. Figure 6: Contacts to Stop Smoking Wales 2004/05 to 2010/11 Number of people contacting Stop Smoking Wales, 2004/ /12 Produced by Stop Smoking Wales / / / / / / / /12 Financial year 27

28 In 2011/12 there was a decrease in the contacts of 1.4 per cent compared to the previous year (figure 6). However, due to the increase of 7.5 per cent from 2009/10 to 2010/11 sustaining a high volume of contacts has been an excellent achievement. The graph below shows the monthly contact data for 2011/12 compared with 2010/11. Figure 7: Contacts month on month comparison April 10/11 to March 11/12 Contacts to Stop Smoking Wales by month, 2010/11 and 2011/12 Produced by Stop Smoking Wales 2010/ / The Adviser was extremely helpful and supportive and made me feel that I would be welcome to continue for as long as necessary and that I could contact her in future if I felt the necessity. It might be helpful to have an extra 2-4 session at progressively longer intervals. 28 Female 56 years

29 5.3 Activity and outcomes for behavioural support programme, by Health Board area, 2011/12 All clients that were scheduled to attend the behavioural support programme for the period 01 April 2011 to 31 March 2012 will be included in the table below. Clients could have contacted before this period or during this period therefore, it will only include a proportion of the contacts in table 3. Table 3: Activity and outcomes, by Health Board area 2011/12 Health Board Area Clients schedule d to attend Attending assessment session only Treated smokers Followed up Quit at 4- weeks self reported % Quit at 4- weeks self reported Quit at 4- weeks CO Validated % Quit at 4-weeks CO Validated Betsi Cadwaladr University Health Board 2, ,335 1, Powys Teaching Health Board Hywel Dda Health Board 2, , Aneurin Bevan Health Board 2, ,129 1, Cwm Taf Health Board 1, Abertawe Bro Morgannwg University Health Board 4, ,108 1,728 1, , Cardiff and Vale University Health Board Wales 15,507 3,139 7,061 5,942 4, ,

30 Of all clients scheduled to attend a session during 01 April 2011 and 31 March ,200 (65.8 per cent) attended and 7,061 became treated smokers. Out of everyone that attended 30.8 per cent only attended an assessment session and out of all clients scheduled 34.2 per cent failed to attend an appointment. Of the 7,061 treated smokers, 5,942 (84.2 per cent) were successfully followed up at four-weeks post quit date, with 4,043 (57.3 per cent) self reporting that they had successfully quit at the four-week follow up (see table 3). The total number of treated smokers who were verified as not smoking at four-week follow up by carbon monoxide monitoring was 2,887 which represents 71.4 per cent of those who self reported abstinence. Out of the 7,061 treated smokers who participated in the six-week behavioural support programme a carbon monoxide validated quit rate of 40.9 per cent was achieved. It should be noted that it is only possible to carbon monoxide validate those clients who attend the week six treatment session as this coincides with four-weeks post quit date. Clients who do not attend this session are followed up by telephone. Consequently only a self reported smoking status can be recorded. With regards to self reported quit status at four-weeks, males over 60 had the highest success rate (63.5 per cent). Overall 59.1 per cent of males self reported that they had successfully quit compared to 55.9 per cent of females. Predictably the majority of treated smokers are from white backgrounds, accounting for 98.5 per cent of those treated, as a result the highest rate (98.5per cent) of self reported quitters are in this group. A more detailed breakdown of activity and outcomes for 2011/12 is provided in Appendix 2. 30

31 5.3.1 Activity and outcomes at 52-weeks All clients that were scheduled to attend a behavioural support session between 01 April 2010 and 31 March 2011 that successfully quit at 4- weeks were eligible to be followed at 52 weeks. The number of clients eligible to be contacted at 52 weeks was 4,510 clients and 2,919 (64.7 per cent) clients were successfully contacted during 2011/12 to ascertain their smoking status 52-weeks post quit date. The results are reported in table 4. The follow up rate ranged from 80.8 per cent in Cwm Taf Health Board to 54.3 per cent in Abertawe Bro Morgannwg University Health Board. Of those eligible to be followed-up, 30.4 per cent had quit at 52-weeks, this ranged from 26.2 per cent in Powys Teaching Health Board to 41.2 per cent in Cwm Taff Health Board Health Board. At a local authority level the quit rates ranged from 45.2 per cent in Rhondda Cynon Taff to 12.0 per cent in Gwynedd. A more detailed breakdown of 52-week follow-up outcomes is shown in Appendix 2. Your councillor was brilliant. Male 65 years 31

32 Table 4: 52-week outcomes, by Health Board area, for clients eligible for follow up by the service between 1 April 2010 and 31 March 2012 Health Board Area Clients eligible to be followed up at 52- weeks post quit date followed up at 52- weeks post quit date quit at 52- weeks (self report) % quit at 52-weeks self report Betsi Cadwaladr University Health Board Powys Teaching Health Board Hywel Dda Health Board Aneurin Bevan Health Board Cwm Taf Health Board Abertawe Bro Morgannwg University Health Board Cardiff and Vale University Health Board Wales

33 5.4 Service developments Stop Smoking Wales has determined, but achievable plans for the next year to build upon the unique quality service that is currently provided to increase through-put through the service. The service has seen a number of management changes and internal reviews over the last few years which has resulted in the extension of deadlines on work already previously started. In we will be committed to ensuring the excellent work that staff and partners have contributed to will be completed with exciting new work streams Research, pilots and developments Research of alternative methods of service delivery and different type of interventions as well as providing the intensive behavioural support programme is currently ongoing. The first pilot of exploring alternative method of service delivery will start during 2012, where the advisors will conduct assessments over the telephone. Intensive research of UK smoking cessation services will be undertaken with a focus on information technology infrastructure, data capture and reporting monitoring information to assist with progression of the integrated e-referral pathway, web based support, on-line booking and extension of text messaging across Wales. Stop Smoking Wales has commissioned the National Centre for Smoking Cessation and Training (NCSCT) in England to provide high quality stop smoking training for smoking cessation advisors. This training is based on the most up-to-date evidence available to the NCSCT. It will enable practitioners of smoking cessation to develop core competencies in particular behavioural change techniques and improve advisors knowledge and skills in the field of cessation. 33

34 It is envisaged that Stop Smoking Wales partners, such as prison staff and mental health practitioners will be able to access the online training and face to face support. Work on the service database Quit Manager has been commissioned for to include electronic referrals directly from hospitals and other providers to work parallel with the current referral pathway. This will allow partners who currently refer clients to the service to access a secure part of the database to record the person s details only. This will then come through directly to the administration team across Wales, reducing time and resource for service, referrer and user. Reports will be designed to record and relay the number of referrals from each organisation and the number becoming clients of Stop Smoking Wales. A review of current working practices has been undertaken and as a result of this review, work will be commissioned for to make significant improvements to the service database that will allow data to be recorded in real-time by advisors at venues. There will also be an investment in equipment for advisors, to allow immediate electronic access to secure networks at venues with subsequent training to support this work. It has been acknowledged that the current process has been under resourced partly due to limitations of current technology, equipment, training requirements, staff resource and restructure of the service has delayed implementation of this work. Very helpful people, Keep it as it is. Sadly I have started smoking again but am determined to give it up. Male 63 years 34

35 5.4.2 Text Messaging The text messaging pilot has been running since 2010 in South East Wales. Stop Smoking Wales explored the use of text messaging as part of the intervention to maintain continued engagement and reduce the did not attend or drop-out rate. All clients were informed of the text messaging service at contact; clients that agreed to receive a text message reminder were sent a text one week prior to the appointment and another text before the appointment. The text messaging service will now be implemented across Wales during , with the aim of adding motivational messages to the texts that are sent. The current evidence shows no effect of mobile phone-based smoking cessation interventions on long-term outcome. However, shortterm results are positive, more thorough studies of the long-term effects of mobile phone-based smoking cessation interventions are required (Whittaker R, et al., 2009). It is anticipated that this will increase the proportion of clients attending the assessment session and are converted to treated smokers and subsequently self report abstinence at 4-weeks post quit date to the service. It is hoped that further analysis can be undertaken during to advance our understanding of the role of text message reminders and motivational messages in smoking cessation. 35

36 5.5 Integrated telephone system In August 2011, a new telephone system was installed in the administration offices across Wales to improve the quality and efficiency of all calls received via the The advantages of the new telephone system are that calls can be distributed to call agents around Wales on a loop system ensuring calls are answered in a rapid response time and calls queued are then minimised. The sophisticated telephone system also allows detailed reports to be produced on a daily basis to help maintain a robust and efficient system. The reports include daily contacts to the free-phone line, call waiting times and peak times of calls. This information has been extremely beneficial as it has enabled a better understanding of peak times, peak days so we can ensure there is an adequate staff resource available to cope with the inherent fluctuation in call volume. The current telephone system has shown that call volume can be between 90 to 170 contacts per day. As a result of this information, research will be conducted through to understand the variation of calls. This is to ensure we capture the nature of all calls to the service. Currently, the service database only records clients who are scheduled to attend an appointment and not those who want information on stopping alone. The service also receives a high volume of calls from health professionals who want further information or those needing information on products or dealing with cravings. Staff gave excellent advice and support. It would be great if we had a smoking support clinic/drop in centre in Newport or even a small stall in the Kingsway centre, town centre or even a supermarket Male 51 years 36

37 Table 5: Number of call to free phone line, from September 2011 until March 2012 Month Number of calls to freephone line received September 2167 October 2188 November 2240 December 1286 January 3262 February 2165 March 2953 Total Quality framework A quality framework is in place for Stop Smoking Wales. This helps to support and develop the delivery of high quality, evidence based smoking cessation provision across Wales. It ensures that issues including consistency and standardisation of the programme, accuracy of data collation and information and competent delivery are reviewed and addressed periodically Service manual The Stop Smoking Wales manual provides a comprehensive guide to delivering the service model, standardised client materials and data collection procedures. The service manual contains the detailed protocols and procedures to ensure standard and consistent service delivery across Wales. All staff delivering the programme receives a copy of the manual, which is the governance framework for staff to adhere to in order to ensure a standardised service delivery model across Wales. 37

38 The service manual is updated to ensure the information is consistent with current working practices, protocols and implementation of new work streams Stop Smoking Wales database Stop Smoking Wales uses a national database to collect formal data on the activity and outcomes from the services delivered across Wales. The service collects data established from the agreed standard criteria used throughout the UK in NHS smoking cessation services. Data is collected on service activity, volume and outcome. Since 2010, data has been collected onto a single service database, Quit Manager. This new client database has the added quality benefit of allowing flexibility of booking to offer consistent customer service. It allows clients to be booked onto an assessment session that is not within the geography of the office that they call. In addition, the in-built validation rules ensure that data is complete and capable of audit to assess quality Audit Audit cycles are in place in Stop Smoking Wales. This year a number of audits across Wales have been conducted on the behavioural support sessions delivered through regular supervision at the sessions which has been inbuilt into local senior staff work-plans. The regular supervision and audits of the behavioural support sessions are to ensure consistency of content and service delivery. 5.7 Health and Safety Stop Smoking Wales have conducted risk assessments of staff, which include any incidents during the course of their work. Public Health Wales has acted on the result of the findings and investment has been made to ensure any high risk situations are minimised. All staff have been issued with torches, personal alarms and in addition advisors have been 38

39 identified as at risk under the lone-working policy and therefore have been provided with a lone worker device, to use through-out the working day. The device allows staff to send a red alert through to a 24 hour call centre, if they perceive they are in a situation of risk or harm, which would initiate an immediate response. Intensive violence and aggression training has been provided. Currently an internal health and safety review is being conducted and the findings will be released in June Risk Assessments All existing and new venues across Wales have been risk assessed and any venues that do not meet the requirements of the risk assessment are not used. Overall very uplifting, I couldn t wait for the next group meeting so sorry that they ended. I would recommend the session to everybody who would like to quit. I am now into my 9 th week of quitting. Thanks to Stop Smoking Wales! Female 51 years 39

40 6. Strategic partnership and direction 6.1 National and local campaigns and events Stop Smoking Wales supported a range of local and national campaigns and events to promote the service and to raise awareness of the health effects of smoking. No Smoking Day is an annual UK evidence based health promotion campaign for smokers who want to stop. The campaign took place on 14 March 2012 with a theme of Take the Leap. Stop Smoking Wales worked with local partners to raise awareness of the campaign and to promote the service. Partners included: Public Health Teams, Community First teams, Organisations involved in the Corporate Health Standard Award Scheme, Secondary Care and Tenovus. Activities included raising awareness in the following settings: Communities First areas Hospitals Shopping centres Government and Local Authority offices Schools, colleges and universities 40

41 No Smoking Day campaign took place on 14 March 2012 with a theme of Take the Leap No Smoking Day stand at the Royal Gwent Hospital in Newport A total of 29 No Smoking Day events were supported by Stop Smoking Wales across the country. Radio adverts were also broadcast on Real Radio (all Wales reach), Capital Radio (South Wales), Heart Anglesey & Gwynedd, Heart North Wales Coast, Heart North East Wales and Cheshire, Radio Ceredigion, Radio Pembrokeshire and Swansea Sound on the lead up to No Smoking Day. A lot of additional innovative publicity was achieved by Local Public Teams across Wales, including a short film which has been very well received. 6.2 Stop Smoking Wales DVD As part of the Stakeholders Communication s Plan to engage with colleagues and partners to increase the recognition of the service, a Stop Smoking Wales DVD was created in The dissemination plan for this resource took place in 2011/12 with partner organisations and stakeholders. This DVD has proved to be an effective promotional tool and is used at training sessions and promotional events across Wales. It 41

42 is planned to have the DVD uploaded onto YouTube to reach a wider audience to improve accessibility and sustainability. 6.3 Real life quitter stories Building on the success of the SSW DVD, Stop Smoking Wales has filmed five in-depth client stories. These stories are smoker s personnel experiences of what life is like when giving up smoking. Stop Smoking Wales intends to use these honest, realistic accounts of smoker s experience of quitting on the SSW website and on You Tube when Public Health Wales Social Media Strategy has been finalised in These stand alone testimonies consist of a mixture of quitters and those who have relapsed. They cover topics such as weight gain, withdrawal symptoms and coping with stress. Viewers will be able to relate to these experiences which may empower them to take action. 6.4 Stop Smoking Wales website The Stop Smoking Wales website was re-launched in January Improvements include new material such as case studies, quitting tips, a smoking calculator and health advice. This re-launch is the first step in a series of revisions to be made to the website. 42

43 6.4.1 Stop Smoking Wales s website statistics from 20 January 2012 to 30 April 2012 Data collected by Google Analytics on how visitors interacted with Stop Smoking Wales, since the new website was launched on 20 January 2012 to 30 April During this period the website recorded 7,802 visits from 6,499 unique visitors resulting in 36,550 web pages being viewed. On average, visitors viewed over four pages per visit and spent over three minutes on the website. The number of daily visits during the period reached its highest on March recording 197 visits (see figure 8). Figure 8: Daily visits to the Stop Smoking Wales website: 20/01/ /04/2012 See appendix 5 for further analysis of website usage. In , Stop Smoking Wales will add further applications to share video footage of real life quitter s experiences and clips from the SSW DVD. 43

44 6.5 Other resources Stop Smoking Wales has worked in conjunction with ASH Wales to develop a smoke-free homes leaflet for dissemination among health visitors across Wales. ASH Wales will lead on the dissemination of this leaflet which will take place in Over the last two years a self help pack has been developed which includes a DVD, self help materials and information on the service. Over the last year 90 of these have been sent out in one area of Wales. This work will be further developed in the coming year. Stop Smoking Wales is also working with colleagues in Welsh Government, on the Fresh Campaign, the smoke free car resources and the self help Quit Kits that have evaluated well in England. They did well because I stopped smoking. I wasn t sure that I wanted to stop. 44 Female 59 years

45 7. Training Supporting others to develop skills in smoking cessation, particularly brief intervention is one of the key objectives of the Stop Smoking Wales Service. This is both in recognition of the important role that brief advice and brief intervention play in recruiting smokers to the service and in recognition that many smokers will access support to quit from other less intensive interventions in a variety of settings. There is strong evidence that health care providers can make a significant difference in helping their clients quit (Stead et al, 2008). Standards for training in smoking cessation practice are important to provide good quality, effective smoking cessation interventions in Wales. This will lead to better consistency of approaches based on a common understanding of the theoretical basis and most effective practices in smoking cessation. ASH Wales and Public Health Wales have jointly produced guidance on standards for training which provide details levels of intervention and associated training. Brief intervention is an evidence based approach to discussing smoking and quitting with smokers, with the aim of triggering a quit attempt. It can be delivered by a broad range of health and community workers. Brief intervention involves a structured, opportunistic discussion during which the practitioner offers information, advice and encouragement to stop smoking, along with referral to intensive support services such as Stop Smoking Wales. The provision of brief intervention is supported by national stop smoking guidance (NICE, 2006). Stop Smoking Wales provides Brief Intervention training across Wales to a range of health and community workers as part of its Programme Level Agreement with the Welsh Government. The brief intervention training programme has been accredited by the Royal College of Nursing and Agored Cymru (formerly Open College 45

46 Network Cymru) since Accreditation adds value to the training programme by ensuring quality and consistency, and by providing professional development and learning credits for participants. A total of 692 participants obtained Royal College of Nursing accreditation and 259 participants submitted evidence portfolios to obtain Agored Cymru accreditation at Level 2. Between April 2011 and March 2012, the service delivered 76 brief intervention one-day training courses to a total of 692 participants. Courses were delivered in each of the 22 local authority areas of Wales. A total of 74 of the courses were offered on an open access basis to a broad range of health and community workers. The main professional groups represented were nurses, health visitors and health care support staff. Two courses were offered to specific teams and professions, including midwives, undergraduate midwives, respiratory nurses, health visitors and pre-operative teams. Since the training was introduced in July 2009, the service has delivered 225 brief intervention one-day training courses to a total of 2,453 participants. Approximately ninety eight per cent of participants (692 participants attending 76 courses) reported that the course provided them with the knowledge and skills to enable them to deliver effective brief interventions including referral of smokers to Stop Smoking Wales. 85 per cent of participants rated the course as excellent in terms of content. A training schedule and promotional flyer was actively marketed to a range of health and community professionals through a number of partnership networks and events, locally and nationally. Feedback suggests that most participants heard about the course by receiving the flyer electronically. Others heard about it through word of mouth from colleagues or at meetings. Few found out about the course from websites, such as the Royal College of Nursing and ASH Wales websites. 46

47 7.1 NHS e-learning Package Stop Smoking Wales is delighted to announce the launch of an e-learning Brief Intervention training package for NHS staff in January We know that around 70% of all smokers want to quit, and that their chances of success can be increased if they are offered a brief intervention. Brief intervention is a method of discussing smoking and quitting in a positive, non-confrontational way to encourage smokers to think about giving up and enable them to access specialist support when they are ready. This training is suitable for all NHS staff that come into contact with smokers on a regular basis. E-Learning provides an accessible alternative to the one-day accredited course offered by Stop Smoking Wales The e-learning package objectives Smoking-related issues and concerns, prevalence, recent changes to the law, the health risks of smoking and the benefits of quitting Understanding why people smoke and why it can be difficult to quit Recognising when a person may be ready to quit Developing practical skills to make effective brief interventions How to refer to Stop Smoking Wales and what the service offers I found the support I received from my session very helpful and the coordinator I found was very polite, friendly and helpful and understanding to my needs. 47 Male 42 years

48 7.2 Information, awareness raising and training for smoking cessation in Wales There are different levels of training which are appropriate to the specific level of smoking cessation intervention being delivered. Smoking cessation interventions range from awareness raising, brief intervention, intensive one to one and group-based behavioural support (ASH/Public Health Wales, 2010). Guidance has been developed on standards for training in smoking cessation practice in Wales and the key purpose of this is to improve the effectiveness of smoking cessation interventions and services collectively. The training has been designed and compiled to promote and support smoking cessation interventions to patients and clients. Stop Smoking Wales is currently developing further training for smoking cessation within the guidance framework. With the aim to support an increase in numbers of Health Board staff who have up to date and accurate knowledge of the national service that Stop Smoking Wales provides and are better equipped to raise the issue of smoking with patients and clients. The training will include the face to face training which supports an increase in those who are trained in brief intervention for smoking cessation. A blended learning option, combining modules from the e-learning package with a half day face-to-face skills training session, is also available to support staff groups unable to be released for a full day. To widely communicate training schedule formats to Health Boards and partners. A set of smoking cessation training and education packages is being developed. It will include awareness raising, educational sessions and an e-learning package. 48

49 8. Primary care engagement General Practice is a key interface through which Stop Smoking Wales is promoted. The service routinely visits practices to promote the service, encourage health professionals to raise the issue of smoking and refer onwards to Stop Smoking Wales. The service also delivers brief intervention training sessions for practice staff. Stop Smoking Wales staff ensure service materials, such as client leaflets, referral cards and posters, are available across primary care settings. Stop Smoking Wales wrote to every GP in Wales in December 2011, encouraging them to use the New Year s resolution period, as an opportunity to provide brief intervention support to smokers and to refer smokers who want support to quit to Stop Smoking Wales. A copy of Stop Smoking Wales DVD was also disseminated to every practice across Wales to promote the service. Over the past year, 68 per cent of clients who contacted Stop Smoking Wales stated that they had heard of the service through their general practice, as highlighted in table 6. Table 6: How clients reported hearing about Stop Smoking Wales, 2011/12 How contacts to Stop Smoking Wales heard of the service, 01 April 2011 to 31 March 2012 Produced by Stop Smoking Wales How client heard about the service Number % of contacts GP / practice nurse Family / friend Other Used service before Hospital Local Referral Pathway to service Leaflet / flyer Pharmacist Internet NHS Direct helpline TV or radio advert Dentist Total

50 The Wales Deanery (Postgraduate Medical and Dental Education) provides information on specialist training for general practice in Wales, the appraisal system, and continuing professional development (CPD) for all GPs in Wales. In early 2010, Stop Smoking Wales commissioned Cardiff University, School of Postgraduate Medical and Dental Education (Deanery) to develop a module on smoking cessation. In late 2010, capacity within the Deanery to undertake this work changed. To ensure that this opportunity was not lost, Stop Smoking Wales undertook the editorial task of compiling the module under the guidance of the Deanery. The module includes a workbook (outlining smoking, smoking cessation and best practice, and pharmacotherapy) and a pre- and post assessment to demonstrate learning has taken place. The module is currently being promoted by CPD and Appraisal coordinators across Wales. Found the programme very successful, though being within a group found it a lot easier to give up smoking. An excellent programme, would recommend it to anyone who wants to quit. Thank you. Female 62 years 50

51 9. Partnerships with community pharmacy Stop Smoking Wales has continued to work closely with Health Boards and community pharmacists to extend and improve client access to nicotine replacement therapy. Community pharmacies serve local communities and have the potential to reach and treat large numbers of people who use tobacco. Stop Smoking Wales has provided training on brief intervention as well as training within the Wales Centre for Pharmacy Education programme. There are currently three levels of smoking cessation service that community pharmacy can provide: Level one: Level two: Level three: The promotion of healthy lifestyles, as part of the core Health promotion activities pharmacists are required to encourage smokers to quit, provide advice on quitting strategies, provide over the counter NRT and signpost to local services Pharmacists supply NRT and support patients receiving counseling from the local smoking cessation service, offering additional support and reinforcement of their advice. The pharmacist role is to ensure the clinical suitability of the NRT and continue to provide brief interventions as for level one Pharmacists provide one-to-one assessment of a client, initiate supply and monitor the use of appropriate smoking cessation therapy, and provide advice and support each time NRT is supplied. The current pharmacy level two scheme is designed to link the intensive behavioural support service provided by Stop Smoking Wales with community pharmacies to improve client access to nicotine replacement therapy. Under this agreement the community pharmacist undertakes to supply nicotine replacement therapy to smokers who are receiving intensive behavioural support from the Stop Smoking Wales service. This is in response to client referral letters from Stop Smoking Wales that 51

52 indicates the client s dependency on nicotine and continued participation in the Stop Smoking Wales intensive behaviour support programme. There is a large body of evidence to show that NRT is extremely effective in helping smokers to stop smoking, where it is shown that NRT approximately doubles the chance of long-term abstinence compared with a placebo (Silagy et al, 2004). Since the introduction of the level two pharmacy scheme, Stop Smoking Wales has seen an increase in contacts, which has also led to more effective supply of nicotine replacement therapy. There is tentative evidence of savings in Health Boards, as a result of spending less on smoking cessation pharmacological aids. This makes the level two scheme an effective intervention without duplicating efforts by other organisations. Stop Smoking Wales will continue to work with the Welsh Government and Health Boards to explore the opportunity to further extend the level two scheme across Wales. If Health Boards decide to contract level three services, then a partnership approach with Stop Smoking Wales will ensure standards are maintained and prevent duplication of services. For example in rural areas such as Powys and Gwynedd that have the level three scheme clients are able to access smoking cessation support where Stop Smoking Wales is unable to provide a service. The enhanced pharmacy scheme aims to provide the level three scheme, across Wales and this is where Stop Smoking Wales can jointly work with the Health Boards Stop Smoking Wales works closely with colleagues from the Public Health Wales Pharmaceutical Public Health Team and Primary Medical Care Advisory Team to periodically update the service protocols and guidance for staff on their role in supporting client access to smoking cessation In developing any local enhanced smoking cessation services in community pharmacy settings, planning for consistent approaches and the ability to evaluate effectiveness in comparison with other smoking 52

53 cessation services across Wales is essential. Public Health Wales will work with Welsh Government in 2012/13 to support the development of smoking cessation by pharmacy, ensuring a consistent service specification model for Wales. There is potential to explore the possibility of Stop Smoking Wales providing mainly group support and pharmacy schemes providing one to one appointments. With Stop Smoking Wales referring clients that would rather a one to one in their community to the pharmacy schemes and those that require group support, accessing Stop Smoking Wales. There is also the possibility of utilising our telephone call centre facility, to provide telephone counselling for specified client groups that cannot access other services. This will enable smoking cessation services to be developed to meet the needs of the population and will help to ensure all services are as effective as possible, accessible and are value for money. In my view the most important period of my time in the process of stopping smoking is between the initial phone call to SSW and the 1 st Appointment at the clinic. I found making the phone call to SSW the most important and critical step. Female 41 years 53

54 10. Pre-operative smoking cessation Stopping smoking before having surgery leads to better health outcomes for individuals. Effective smoking cessation interventions six to eight weeks before a person has surgery can lead to short-term smoking cessation among smoker and as a consequence reduce post-operative morbidity (Thomsen et al, 2010; Moller et al, 2002). In terms of cost saving, there is also the potential to save up to 2.3 million across Wales if patients stop smoking prior to elective surgery as they will be healthier post operatively and this will in turn lead to reduced hospital stay (Bowles, 2007). The pre-operative scheme in Stop Smoking Wales is called Get Well Sooner and during 2011/12 targeted promotional work has aimed to strengthen the route into smoking cessation services for elective surgery patients who smoke and want to stop. Stop Smoking Wales has continued to work with each Health Board to encourage and support patients awaiting elective surgery to stop smoking in preparation for their operation. In partnership, we will undertake further work to strengthen referral pathways for pre-operative smoking cessation, exploring direct referral mechanisms and opt-out systems along with linking smoking cessation within clinical care pathways Increasing staff knowledge and understanding of the key benefits of preoperative smoking cessation is essential. This is designed to increase the number of effective brief interventions undertaken with patients, and consequently increase numbers of patients making quit attempts prior to surgery. Stop Smoking Wales helped to increase the knowledge and skills of Health Board staff through the delivery of information and awareness raising sessions across Wales. This has taken place in a variety of primary and secondary care settings including outpatients departments, clinics and surgical wards. 54

55 Stop Smoking Wales have worked with Health Boards to ensure advice on giving up smoking is given to patients prior to an operation. Information about the service is provided through patient information leaflets and documents. All hospitals have been provided with Stop Smoking Wales resources, including the pre-operative smoking cessation Get Well Sooner leaflets and posters. Direct referral mechanisms between Health Boards and Stop Smoking Wales, via fax, and internal electronic mechanisms have now been established in many hospital departments across Wales. Referral pathways have also been strengthened through partnership work to develop paperwork such as patient assessment forms to include questions on smoking and quitting, and prompts for brief intervention and referral to Stop Smoking Wales. A review of the role that direct referral pathways play in increasing the number of contacts and treated smokers will be undertaken in 2012/13 and will help to inform further expansion of this approach if it is found to be beneficial. In early 2012, Stop Smoking Wales has produced run charts to feedback to Health Boards (see appendix 4). The only thing that I would find more useful is if the support group could run longer. Seven weeks in my view is not long enough and I find that maybe people would start smoking again because they then feel on their own. 55 Female 39 years

56 11. Pregnant Women The Infant Feeding Survey found that more mothers living in Wales smoke throughout pregnancy than in any other area of the UK (NHS Information Centre, 2011). Smoking in pregnancy is associated with a number of serious consequences for the health of the baby including low birth weight, premature birth and perinatal death. Growing up in a household in which babies and children are exposed to cigarette smoke impacts on their health and wellbeing. (NICE, 2008). Building on the success of the pilot work introduced during 2009/10, Stop Smoking Wales has gone on to implement direct referral pathways across every Health Board area in Wales. These direct referral pathways have been implemented aiming to strengthen the referral system from antenatal units to the service in line with national guidelines. The referral pathway has been strengthened by introducing an opt-out system which allows pregnant smokers to automatically be referred to Stop Smoking Wales unless they opt not to be referred. This has been supported by ensuring that midwives have received brief intervention or awareness raising training on smoking cessation and the protocol for the new referral pathway which will allow them to effectively discuss smoking with pregnant women and their partners A standard referral form for midwives to use in referring pregnant smokers to Stop Smoking Wales is also available. Carbon copy books of the referral form have been produced for specific maternity services that have predominantly community based midwives. This form requires the midwife to provide pregnant smokers with the Stop Smoking Wales maternity leaflet as well as the smoke free living leaflet. With the development of the e-referral system in , this will be made available to midwifery services across Wales to access. This will speed up the referral process for pregnant women accessing support. It 56

57 will also provide feedback to the midwife as to the outcome of the referral. Stop Smoking Wales supports pregnant women across Wales who want support to stop smoking. The service delivery model for delivering services to pregnant clients differs from the general delivery model. The evidence suggests that this group should receive a dedicated service pathway and this is currently being offered by Stop Smoking Wales on a one to one face to face or telephone basis. Clients are offered and may join one of the community based group support groups if they wish. The partner of the pregnant smoker can also access the service if they want support to quit smoking. Stop Smoking Wales Advisors have received additional training in motivational interviewing techniques supporting pregnant women and this was specific training for this target group. Many pregnant smokers who are referred onto SSW through the opt out referral system are willing or at the stage where quitting is deemed important for them. A guide for use when making initial contact with a smoker who has been referred to SSW by a midwife has been developed to maximise the effectiveness of this intervention. Strengthening the referral pathway by influencing changes to current maternity services data collection procedures is a key area for development. The Welsh Government has revised the All Wales Maternity Health Record in 2011/12. Stop Smoking Wales contributed to this revision and are pleased to report that questions pertaining to whether the pregnant smoker wishes to be referred to a smoking cessation programme are now included. This prompt for midwives will ensure consistency in the provision of services being offered to all pregnant smokers. NICE (2010a) recommends that maternity services introduce carbon monoxide monitoring of all patients as a routine test at the booking in 57

58 appointment. Therefore, Stop Smoking Wales have purchased additional CO monitors for use by Health Boards who wish to introduce CO monitoring within antenatal departments. Stop Smoking Wales will support departments who wish to pilot CO monitoring by providing expertise and training in this area. Stop Smoking Wales plan to work with maternity services across all the Health Boards in Wales during 2012/13 to ensure that all pregnant women in Wales are encouraged to access support to quit. In early 2012, Stop Smoking Wales has produced run charts to feedback to Health Boards, (see appendix 3). I have used this service twice and found group session much more helpful than 1:1. Female 34 years 58

59 12. Services for vulnerable groups 12.1 Smoking and mental health Smoking has a significant impact on the health of people with mental health illness and is a Public Health concern. Smoking rates are higher than in the general population and have a disproportionate impact on morbidity and mortality of people with mental health problems (McManus et al, 2010). Smoking prevalence varies across the mental health diagnosis (McNeill, 2001; Meltzer et al., 1995) and is highest amongst those with schizophrenia, neurotic disorders, affective psychosis and homeless people. Whilst prevalence of psychotic disorder is low in the general population (Coulthard et al., 2000; McNeill, 2004), one in four British adults experience at least one diagnosable mental health problem in any one year, and one in six people experience this at any given time (Office for National Statistics, 2001). In Wales, smoke free legislation has provided exemption to mental health units that provide residential accommodation to patients. The Welsh Regulations provide for a permanent exemption, where Hospital managers can provide designated smoking rooms (National Assembly for Wales, 2007). The service is currently working with mental health Services to explore options for restricting smoking in inpatient facilities in Wales. Stop Smoking Wales continues to provide behavioural support for clients with mental health problems who live in the community and who would like to give up smoking. It does not however, provide the service for inpatients in mental health care hospitals. Nevertheless, the plan is to provide a mental health toolkit, to emulate the prison toolkit for mental health staff to deliver smoking cessation support to clients. 59

60 Stop Smoking Wales does not record the client s health status and therefore, it is not routinely possible to report on the number of clients with a mental health illness that use the service. During 2012/13, Stop Smoking Wales will work with partners in mental health care settings to: provide brief intervention training for mental health practitioners working in community settings promote and encourage smoke free environments in hospital settings and address the cultural barriers in this setting arrange training for Stop Smoking Wales staff in working with clients with mental health problems develop a mental health smoking cessation toolkit 12.2 Young People The current pattern of smoking in children and young people illustrates health inequity in Wales. The most recent data on school aged children and smoking shows that children from the most affluent families are less likely to smoke than those from the middle and lowest affluence groups, (Welsh Government, 2011). Children from the least affluent families also start smoking at a younger age and are more likely than those in the highest affluence group to have smoked by the age of 13. This has relevance to smoking cessation services, as the earlier an individual starts to smoke, the more dependent they are as adult regular smokers and the more they require intensive behavioural support to successfully stop smoking. The Health Behaviour of School-aged Children (HBSC) report in 2009/10, looked at the health of children in 39 countries. Presently in Wales 0.5 per cent of 11-year old children reported smoking at least once a week and amongst 13-year olds, 2.7 per cent of boys and 5.2 per cent girls 60

61 report smoking at least once a week (HBSC, 2009/10). Amongst 15-year olds, 9.6 per cent boys and 14.8 per cent girls report smoking at least once a week (HBSC, 2009/10). Girls are more likely to smoke than boys, and more likely to start smoking at a younger age. Regular smoking behaviour increases between the ages of 11 and 16 years. Young smokers patterns and levels of smoking are often different from those of longer, established adult smokers. Whilst delivering smoking cessation services is well documented as an effective intervention to help adults to stop smoking (West et al, 2000), there is relatively little research on effective smoking cessation interventions for young people to inform the development of these services (Thomas and Perera, 2006). Stop Smoking Wales continues to seek out new work in this to identify promising approaches in the field as they emerge. This is also identified as an area for research and development. Separate national guidance applies to smoking prevention strategies which is outside the remit of this report (NICE, 2008, 2010b). Stop Smoking Wales provides support to young people, aged 12-17, who classify themselves as smokers, to help them stop smoking. sessions are delivered on a one-to-one basis. These A total of 184 females and 135 males under the age of 18 accessed the services of Stop Smoking Wales during 2011/12. Activity and outcomes for young people who attended the service in 2011/12 are reported in Appendix 2. Stop Smoking Wales will continue to support young people on a one to one basis. The service will also ensure that Stop Smoking Wales materials are available in educational and other appropriate settings so that young people, aged 12 to 17, who want to stop smoking are aware of the service. As previously stated, Stop Smoking Wales will support and 61

62 refer clients to our partner organisation ASH, that are setting up an innovative service for young people Prison health There are five prisons in Wales: HMP Swansea, HMP Usk, HMP Prescoed, HMP Cardiff and HMP Parc in Bridgend (Parc is managed through the private sector), all of which are located in South Wales. The total prison population in Wales in March 2012 was 3178 (HM Prison Service, 2012) and it is estimated that around 80 per cent of prisoners smoke (Department of Health, 2003). Health Needs Assessments were conducted by Public Health Wales during 2009 for each prison in Wales, and have highlighted smoking cessation as a priority, because of the high smoking rates within this population. Stop Smoking Wales has established partnerships with each prison site to discuss and address smoking issues since this date Stop smoking in prisons toolkit Stop Smoking Wales has developed a Stop Smoking in Prison Toolkit to support access to consistent and effective smoking cessation services for smokers within prison settings who would like to stop smoking. The toolkit contains a smoking cessation service delivery model for the prison setting, outlining the evidence base and recommended approach for delivering smoking cessation support in this setting. The standard Stop Smoking Wales six-week intense behavioural support programme has been tailored specifically for the prison setting, to address the needs of the target population. The approach taken involves prison staff delivering the behavioural support programme in-house. Protocols and guidelines have been written to support prison staff with service delivery. The Stop Smoking in Prisons Toolkit has now been presented to each Prison Health Partnership Board for agreement during 2011/12. 62

63 It is anticipated that Prisons will identify dedicated prison staff and arrange appropriate training to deliver the Stop Smoking Wales behavioural support programme using the toolkit. Stop Smoking Wales will provide support to prisons to ensure consistency of intervention, collate information and adherence to best practice. I would have liked to see the course run for longer, i.e. monthly after the 6 weeks Male 50 years 63

64 13. Workplace health Reducing levels of smoking among employees can contribute to reducing illnesses and conditions, such as cardiovascular disease and respiratory diseases, which are significant cause of sickness absence. This results in improved productivity and less costs for employers (NICE, 2007). The workplace has several advantages as a setting for smoking cessation interventions. Large numbers of people can be reached (including groups who may not normally consult health professionals, such as young men); there is also the potential to provide peer group support, and a smoke free working environment supports people to quit. Employers are not legally obliged to help employees to stop smoking but this can contribute towards reducing the risk of non-compliance with the smoke free legislation. By encouraging their employees to stop smoking, employers will be promoting healthy living and no smoking within society. Black (2008) suggests that it is necessary to ensure that employers and employees recognise not only the importance of preventing ill health, but also the key role the workplace can play in promoting health and wellbeing. From 1 April 2011 to 31 March 2012 Stop Smoking Wales has supported and delivered smoking cessation groups to 41 workplaces across Wales, and of those 41 workplaces 303 clients have received support to stop smoking through workplace based interventions. Close links with the Healthy Working Wales team continues to present opportunities for further development. 64

65 13.1 Smoking cessation guidance Stop Smoking Wales has developed guidance to assist employers to help employees to stop smoking. The guidance has been developed for incorporation into the Corporate Health Standard package. The Corporate Health Standard is one of the Healthy Working Wales programmes, delivered by Public Health Wales and is the quality mark for workplace health promotion in Wales. The Standard is available to public and private sector organisations implementing practices to promote the health and wellbeing of their employees. The guidance has also been included in the Small Workplace Health Award (for workplaces with less than 50 employees) delivered by Public Health Wales Smoke free hospitals During 2011/12, Health Boards across Wales have committed to extending the smoke free legislation to cover all hospital grounds, as well as buildings, being smoke free. The Health Boards act as an exemplar employer by promoting smoke free environments to discourage smoking, help smokers to quit and to promote health and wellbeing to their patients and the public. NHS staff are role models for promoting health and healthy behaviours. Stop Smoking Wales has worked in partnership with Health Board s in supporting the smoke free hospital agenda. Both, giving support to those staff who want to quit smoking, and those who just want to manage cravings in work. Stop Smoking Wales have also, trained staff, in the delivery of brief intervention to colleagues and patients. Stop Smoking Wales will continue to support workplaces to deliver stop smoking support to employees who want to stop smoking, including further work to support smoke free hospitals during and NHS staff who would like to stop smoking 2012/13. 65

66 In addition to the accredited course, work is underway to develop a set of training, awareness raising and educational sessions to increase support for good quality brief interventions at every opportunity. Stop Smoking Wales are working closely with a 1000 Lives campaign, to use the Olympics as an opportunity to encourage NHS staff to access support in cessation. A website is being developed, which will be live in June What a wonderful service you are. I am so grateful for all your time and help and I will miss the sessions. Thank you again so much. Female 21 years 66

67 14. Conclusion Stop Smoking Wales endeavours to develop the service to emerging challenges and will continue to strive for excellence. Although last year has presented some major challenges, good progress continues to be made. Stop Smoking Wales is firmly embedded in the tobacco control plan. We endeavour to be innovative, whilst evolving with current technologies and with our partners play a small, but vital role in the denormalisation of tobacco use and eradicate tobacco harm in Wales. The staff attitude was wonderful - just the right balance - no patronising, mood kept light but not jocular. I have smoked for 48 years and just couldn't stop on my own. SUPERB! Female 62 years 67

68 Acknowledgements Editorial group Katrina Hargrave Rhiannon Hobbs Bethan Jenkins Emma Rogerson Ceriann Tunnah Hugo van Woerden Senior Health Promotion/Public Health Practitioner Senior Health Promotion/Public Health Practitioner Senior Health Promotion/Public Health Practitioner Support Officer Senior Health Promotion/Public Health Practitioner Director of Health and Health Care Improvement Contributors Hugo Cosh Nathan Lester Michael O Connor Margaret Webber Zoe Bailey Katrina Hargrave Rhiannon Hobbs Lauren Idowu Rachel Jayne Bethan Jenkins Rebecca Lewis Nia Lewis-Oliver Cindy Marsh Rhiannon Phillips Emma Rogerson Katie Tulloch Ceriann Tunnah Vikki Wood Virginia Allen-Walker Lucy Morgan Hugo van Woerden Advance Health Information and Intelligence Analyst Head of Health Information and Intelligence Web Editor Health Information and Intelligence Analyst Admin Officer Senior Health Promotion/Public Health Practitioner Senior Health Promotion/Public Health Practitioner Health Promotion/Public Health Practitioner Admin Officer Senior Health Promotion/Public Health Practitioner Health Promotion/Public Health Practitioner Stop Smoking Senior Advisor Consultant in Public Health: Health Improvement Senior Health Promotion/Public Health Practitioner Support Officer Data Practitioner/ Public Health Practitioner Senior Health Promotion/Public Health Practitioner Health Promotion/Public Health Practitioner Stop Smoking Advisor Stop Smoking Advisor Director of Health and Health Care Improvement 68

69 Appendices Appendix 1: Previously, Stop Smoking Wales reports were produced in July of the following year for April to March data set. There is a time lag, as a treated smokers information takes a minimum of three months to be collated before reporting. This year there is a change to the data activity and outcomes reporting methodology. The report has included the number of clients contacting the service is between, 1 April 2011 to March However, outcomes and activity will be based on clients that were scheduled to attend the behavioural support programme between 1 April 2011 and March

70 Calculation of service outcomes 1. The Russell Standard (Clinical) (West, 2005) is widely accepted as the leading standard for calculating outcomes in smoking cessation services. 2. The following definitions from the Russell Standard have been used to produce the service outcomes for 2010/11: i. Treated smoker A smoker who undergoes at least one treatment session. Smokers who attend an initial information session but fail to attend thereafter are not counted. ii. Four-week quitter (self reported) A smoker is counted as a four-week quitter (self-report) if he/she is a treated smoker, who is assessed (face-to-face, by postal questionnaire or by telephone), four weeks after the designated quit date and declares that he/she has not smoked even a single puff of a cigarette in the past two weeks. iii. Four-week quitter (carbon monoxide [CO]-verified) A smoker is counted as a four-week quitter (CO-verified) if he/she is a self reported four-week quitter and his/her expired air CO is assessed four weeks after the designated quit date and found to be less than 10ppm. iv. Lost to follow-up A treated smoker is counted as lost to follow-up if, on attempting to determine the four-week quit status, the client cannot be contacted. v. 52-week quitter A smoker is counted as a 52-week quitter if they are a four-week quitter (selfreport) and if when contacted at 52-weeks (by postal questionnaire or by telephone) report that they have smoked no more than five cigarettes over the past 50 weeks. 70

71 Appendix 2: Monitoring data Contacts to Stop Smoking Wales, 01 April 2011 to 31 March 2012, health board and local authority Contacts to Stop Smoking Wales, 01 April 2011 to 31 March 2012, health board and local authority Analysed by Stop Smoking Wales Health board/local authority area No. of contacts Isle of Anglesey 240 Conwy 552 Denbighshire 441 Flintshire 1065 Gwynedd 157 Wrexham 374 Betsi Cadwaladr University Health Board 2,829 Powys Teaching Health Board 677 Carmarthenshire 1453 Ceredigion 302 Pembrokeshire 695 Hywel Dda Health Board 2,450 Blaenau Gwent 469 Caerphilly 770 Monmouthshire 220 Newport 585 Torfaen 495 Aneurin Bevan Health Board 2,539 Merthyr Tydfil 507 Rhondda Cynon Taf 1045 Cwm Taf Health Board 1,552 Bridgend 935 Neath Port Talbot 1584 Swansea 2242 Abertawe Bro Morgannwg University Health Board 4,761 Cardiff 751 The Vale of Glamorgan 222 Cardiff and Vale University Health Board 973 Wales 15,781 71

72 Contacts to Stop Smoking Wales 01 April 2011 to 31 March 2012 by gender, age and ethnic group Analysed by Stop Smoking Wales Gender Age band No. of contacts ABMU LHB Aneurin Bevan LHB Betsi Cadwaladr University LHB Cardiff and Vale University LHB Cwm Taf LHB Hywel Dda LHB Powys Teaching LHB Female All ages 1 9,007 2,766 1,449 1, , under Male All ages 1 6, ,090 1, , under , , , Persons All ages 1 15,781 4,761 2,539 2, ,552 2, under , ,459 1,217 1, , Persons All persons 2 15,781 4,761 2,539 2, , W hite 15,577 4,716 2,498 2, , Mixed Asian Black Other includes age not given 2 includes ethnic group not given ` 72

73 How contacts to Stop Smoking Wales heard of the service, 01 April 2011 to 31 March 2012 Analysed by Stop Smoking Wales How client heard about the service Number % of contacts GP / practice nurse Family / friend Other Used service before Hospital Local Referral Pathway to service Leaflet / flyer Pharmacist Internet NHS Direct helpline TV or radio advert Dentist Total

74 Outcome and activity of groups/1:1 sessions, 01 April 2011 to 31 March 2012, health board and local authority (Information on people scheduled for an appointment only in this period) Analysed by Stop Smoking Wales Health board/local authority area No. of clients booked to attend No. attending assessment session only No. of treated smokers No. followed up at fourweeks post quit date No. quit at fourweeks (self report) % quit at fourweeks (self report) No. quit at four-weeks (CO validated) % quit at four-weeks (CO validated) Isle of Anglesey Conwy Denbighshire Flintshire Gwynedd Wrexham Betsi Cadwaladr UHB 2, ,335 1, Powys Teaching Health Board Carmarthenshire Ceredigion Pembrokeshire Hywel Dda HB 2, , Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen Aneurin Bevan HB 2, ,129 1, Merthyr Tydfil Rhondda Cynon Taf Cwm Taf HB 1, Bridgend Neath Port Talbot Swansea ABMU HB 4, ,108 1,728 1, , Cardiff The Vale of Glamorgan Cardiff and Vale UHB Wales 15,507 3,139 7,061 5,942 4, ,

75 Outcome and activity of groups/1:1 sessions, 01 April 2011 to 31 March 2012, gender, age and ethnic group (Information on people scheduled for an appointment only in this period) Analysed by Stop Smoking Wales Gender Age band No. of contacts Attended info session only Treated smokers No. followed up No. quit at four weeks (self report) % quit at four weeks (self report) No. at four weeks (CO validated) % quit at four weeks (CO validated) Female All ages under Male All ages under Persons All ages under Persons All persons 2 15,507 3,139 7,061 5,942 4, , White 15,276 3,070 6,955 5,851 3, , Mixed Asian Black Other includes age not given 2 includes ethnic group not given 75

76 Clients eligible to be contacted at 12 months with outcomes, health board and local authority (Information on people scheduled for an appointment only in this period) Analysed by Stop Smoking W ales Health board/local authority area No. eligible to be followed up at 52- weeks post quit date No. followed up at 52-weeks post quit date No. quit at 52- weeks (self report) % quit at 52- weeks (self report) Isle of Anglesey Conw y Denbighshire Flintshire Gw ynedd W rexham Betsi Cadwaladr UHB Powys Teaching Health Board Carmarthenshire Ceredigion Pembrokeshire Hywel Dda HB Blaenau Gw ent Caerphilly Monmouthshire New port Torfaen Aneurin Beven HB Merthyr Tydfil Rhondda Cynon Taf Cwm Taf HB Bridgend Neath Port Talbot Sw ansea ABM UHB Cardiff The Vale of Glamorgan Cardiff and Vale UHB Wales

77 Number and proportion of smokers treated by Stop Smoking Wales, Wales and local authorities, 1 April March 2012 Local authority Percent population smokers - Welsh Health Survey Population Est. number smokers If 5% treated Number treated % and count Percent treated Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire Carmarthenshire Swansea Neath Port Talbot Bridgend The Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport Wales 24 2,381, Analysed by Public Health Wales Observatory, using Stop Smoking Wales data, mid year population estimates 2010 (ONS), Welsh Health Survey 2009/10 (WG) 77

78 Appendix 3 Statistical Process Control Charts Statistical Process Control (SPC) charts can be used to show variation in a process over time. The mean is shown as a central horizontal line on the charts, with lower (LCL) and upper confidence limits (UCL) shown as lines above and below the mean. The UCL and LCL are usually set at three standard errors above or below the mean. Important changes in a process over time can typically be identified by the following patterns in the data: 1. Any data point above the UCL or below the LCL lines, which shows that there is a low probability that this difference occurred by chance alone 2. A run of seven points or more points all above or all below the centre line 3. A run of seven or more points all increasing or decreasing 4. Unusual trends within the UCL and LCL control lines, such as cyclic changes or a consistent trend or increasing or decreasing values 5. The amount of variation in the data around the mean ( i.e. whether or not 2/3 or more of the data points fall within the middle third of the area between the confidence limits) Therefore, SPCs can help us identify important changes in a process over time. In this report, we have used SPCs to illustrate variation in rates of referrals/contact with Stop Smoking Wales in each Health Board from April 2012 to March 2012 with in two groups that are of special interest to the service as they have been identified as high risk group; pregnant women and people awaiting surgery. There are peaks and troughs in the data which indicate variation month by month. However, it is important to note that the criteria listed above should be taken in to account in interpreting the charts as we are looking for statistically significant or consistent changes in contact rates over time. 78

79 For more information on interpreting SPC charts please visit: ity_and_service_improvement_tools/statistical_process_control.html Run charts for Health Boards number of maternity contacts per 100 live births month. (Pregnant women referred to Stop Smoking Wales from antenatal clinics). Notes on maternity data: In general, the SPCs indicate that there has been a gradual increase in maternity contacts with Stop Smoking Wales between April 2012 and March 2012, although there is some variation in the mean contact rate and extent of change across Health Boards. There also appears to be a trend for increased maternity contacts following key activities by SSW (e.g. training and launch events). However, it is important to note that in some cases contact rates begin to drop back down a few months after these activities highlighting the need for continued efforts to engage regularly with Health Boards. Run charts for maternity contacts to Stop Smoking Wales between 1 April 2010 and 31 March 2012 by Health Board are provided below. The rate provided is per 100 live births per month which has been calculated by dividing the yearly births by 12. It should be noted that the live birth data are for 2010 as this is the latest data available. The information is based on the Health Board in which the client lives. 79

80 Abertawe Bro Morgannwg Health Board The mean rate of contacts between April 2010 and March 2011 was 0.14 per 100 live births. Maternity referral pathways were launched in August 2010 in Neath Port Talbot, April 2011 in Bridgend and November 2011 in Swansea. A rise in maternity contact rates in the months following the launches can be seen. 80

81 Aneurin Bevan Health Board Until April 2011 the rate of maternity contacts per 100 live births remained at less than There was a sharp rise in the rate from December 2011 which coincided with presentations by Stop Smoking Wales to the midwifery team and the launch of a referral pathway. The mean rate of maternity contacts between April 2010 and March 2012 was 0.76 contacts per 100 live births. 81

82 Betsi Cadwaladr Health Board The mean rate of maternity contacts per 100 live births between April 2010 and March 2012 was 1.70 peaking at 3.38 in May With the exception of June and December 2011 the contact rate remained above the average of 1.70 from April

83 Cardiff and Vale Health Board Stop Smoking Wales development work with maternity departments in Cardiff and Vale began in March 2011 which coincided with a peak in the rate of contacts in May Since May 2011 the rates varied between 1.55 and 4.07 contacts per 100 live births. The mean rate of maternity contacts between April 2010 and March 2012 was 2.20 per 100 live births. 83

84 Cwm Taf Health Board Maternity contacts to Stop Smoking Wales peaked in December 2010 at 6.82 per 100 live births. This followed a period of training and meetings with midwives starting in May The mean rate of maternity referrals between April 2010 and March 2012 was 2.40 per 100 live births 84

85 Hywel Dda Health Board Meetings with maternity services in Hywel Dda began in April 2011 which coincided with a rise in the rate of maternity contacts per 100 live births in the following five months. The maternity referral pathway was officially launched in November 2011 which again coincided with a rise in rates. Between April 2010 and March 2010 the mean rate of referrals per 100 live births was

86 Powys Health Board There was a rise in the rate of maternity contacts to Stop Smoking Wales following the launch of the referral pathway in January Since this time rates have peaked at 5.98 contacts per 100 pregnant smokers. The mean rate of maternity contacts per 100 live births was 2.60 between April 2010 and March

87 Appendix 4 Run charts for Health Boards pre-operative contacts per 10,000 population The run charts are provided below for each Health Board. The data indicates a clear rise in clients in Aneurin Bevan Health Board and some indication of a rise in contacts in Abertawe Bro Morgannwg University Health Board, Betsi Cadwaladr University, Cardiff and the Vale University, Cwm Taf, Hywel Dda and Powys University Health Boards. Abertawe Bro Morgannwg University Health Board preoperative contacts per 10,000 population 87

88 Aneurin Bevan Health Board pre-operative contacts per 10,000 population Betsi Cadwaladar Health Board pre-operative contacts per 10,000 population 88

89 Cardiff and Vale Health Board pre-operative contacts per 10,000 population Cwm Taf Health Board pre-operative contacts per 10,000 population 89

90 Hywel Dda Health Board pre-operative contacts per 10,000 population Powys Teaching Health Board pre-operative contacts per 10,000 population 90

91 Appendix 5 Analysis of website usage Stop Smoking Wales s website statistics from 20 January 2012 to 30 April 2012 Data collected by Google Analytics on how visitors interacted with Stop Smoking Wales since the new website was launched on 20 th January 2012 to 30 th April 2012 During this period the website recorded 7,802 visits from 6,499 unique visitors resulting in 36,550 web pages being viewed. On average, visitors viewed over 4 pages per visit and spent over three minutes on the website. The number of daily visits during the period reached its highest on March 14 th 2012 recording 197 visits (see figure 1). Figure 1: Daily visits to the Stop Smoking Wales website: 20/01/ /04/2012 For Welsh language pages on the website, 140 page views were recorded with 33 different page titles being viewed. Visitors spent on average close to one minute on each page. 91