BTS Audit of hospital-based Tobacco Dependency Treatment Services finds modest improvement since 2019

Today the Society published its 2021 national Audit of the Management of Tobacco Dependency in Acute Care Trusts, following previous iterations in 2019 and 2016 (2,3). As in previous years, the Society looked at how effectively the national standards for the medical management of tobacco dependent smokers that attend hospitals have been implemented across the UK.

The Audit involved 120 acute hospitals in the UK and the analysis of over 14,000 patient records, and found that in 2021 the NHS was still some way off fulfilling its commitment(1) to help all hospitalised patients that smoke to quit by 2023/4.

In fact, the results are largely comparable with the findings of the previous audit in 2019, and show that the NHS might have missed opportunities by not reaching smokers with advice and treatment when they were already within the healthcare system.

The 2021 Audit revealed that recording of smoking status in patients remained below target, with 79% people admitted to hospital had their smoking status recorded compared to 77% in 2019.

Of the people that were identified as smokers:

• Less than half (45%) were provided very brief advice (VBA) to quit.
• Only 40% were offered a referral to a tobacco dependency service (down from 44% in 2019).
• Fewer than 1 in 10 (9%) were seen by a tobacco dependency practitioner while in hospital.
• Only 1 in 20 (5%) were provided with the most effective interventions recommended by NICE (4) (nicotine replacement therapy-NRT, varenicline-a medicine that reduces cigarette cravings, and vaping).

However, there were also some encouraging improvements in the data; the number of people who smoke admitted to hospital declined slightly, with 21% of acute patients smoking in 2021 compared to 24% in 2019. Also circa 1 in 7 (15%) patients that smoke were referred to a hospital OR community-based smoking cessation service, compared to 1 in 8 (12%) in 2019 and 1 in 12 (8%) in 2016.

Dr Matt Evison, BTS clinical audit lead, commented:

“This BTS audit unfortunately shows that we are still struggling to make meaningful progress in helping patients quit smoking at a national level. However, despite the disappointing figures from last year, I am confident we are approaching a turning point.

“Since we raised concerns about the state of hospital-based smoking cessation services in of our 2019 audit, the NHS has shown a renewed commitment to do better, with dedicated funding for tobacco dependence treatment and the appointment of a National Specialty Advisor for Tobacco Addiction. NICE also published new guidance on treating tobacco dependence, which gives more clarity to clinicians on how to support patients who smoke.

“Most of these initiatives came into being too late for their effect to be seen in our audit, but everything is in place now and we will keep a close eye on the next iteration. While the results are disappointing today, I am looking at this audit as the start, the baseline against which we now need to improve.”

The British Thoracic Society is working with NHSE/I to support clinicians in establishing and improving tobacco dependence treatment services in their trust through its Tobacco Dependency Project, which is providing free resources and educational material for those setting up such a service.

The audit also showed that:

• Only 1 in 3 were offered pharmacotherapy in hospital (NRT, varenicline, same as 2019).
• More hospitals have hospital-based smoking cessation services than in 2019 (41% versus 38%) but referrals are accessible to all healthcare professionals only in half of them.
• Only 1 in 3 hospitals have a dedicated hospital-funded smoking cessation practitioner (same as in 2019).
• Only 50% of trusts offers frontline staff regular smoking cessation training, same as in 2019 and 2016.
• 1 in 5 (18%) hospitals still have smoking areas (down from 28% in 2019), and vaping was permitted in almost a third (30%) of hospital grounds.

Dr Paul Walker, BTS Chair, said:

“The findings of this audit are stark, but the NHS has been under unprecedented strain since we ran the previous audit, which might go some way to explain a slower than expected progress on its commitment to patients who smoke.

“To fulfil the ambition of the Long Term Plan in smoking cessation we need enough of the right staff to set-up and run tobacco dependence services. It is clear for all to see, though, how success here hinges on a national, long term workforce planning exercise.

“Audits are a powerful way to reveal areas that need improvement and in particular, where efforts should be focussed. I hope our audit will give impetus to trusts and show them the direction they need to travel in.  BTS is here to help them doing so, with our new programme to support clinicians that are setting-up of tobacco treatment services.”

BTS used the results of this audit to set a number of national improvement objectives to improve the medical management of tobacco dependent smokers and fulfil the Long Term Plan ambition.

1. All hospitals should identify a healthcare professional(s) to lead on the delivery of a tobacco dependency treatment service and appoint an executive level board member to support the service (immediate).
2. All hospitals should introduce a system of regular local data collection of adult inpatient tobacco-dependency pharmacotherapy prescribing to drive on-going improvement and further encourage delivery of NICE recommended interventions (3-6 months).
3. Ensure all adult patients admitted to hospital have their smoking status recorded (3-6 months).
4. Introduce a training package available to all front-line staff to ensure a minimal level of competence in supporting and treating tobacco dependency (e.g. Very Brief Advice) and implement a system of monitoring uptake (6 months).
5. At least 90% of tobacco dependent adult inpatients to receive Very Brief Advice during the course of their inpatient stay (before next national audit).
6. Offer all hospitalised tobacco dependent patients a referral to a specialist on-site tobacco dependency treatment service (before next national audit).
7. Establish a system to monitor the number of patients provided with Very Brief Advice and referred to (and engaging with) a specialist tobacco dependency treatment services (next 12 months).

References:

1 - https://www.longtermplan.nhs.uk/online-version/chapter-2-more-nhs-action-on-prevention-and-health-inequalities/smoking/

2 – BTS Smoking Cessation Audit 2019 https://www.brit-thoracic.org.uk/document-library/quality-improvement/audit-reports/smoking-cessation-audit-report-2019/

3 – BTS Smoking Cessation Audit 2016 https://www.brit-thoracic.org.uk/media/70159/bts-smoking-cessation-audit-report-7-december-2016-final.pdf

4 - NICE Tobacco: preventing uptake, promoting quitting and treating dependence (NG209)