hand with crushed cigarette

Giving the green light to stopping 2

NHS statistics on stop-smoking services in Scotland were published yesterday. We take a more detailed look at the long-term success rates of these services.

Do they offer good value for money? 

‘Smoking cessation’, or in normal language ‘stopping smoking’ is something we’re naturally very interested in at ASH Scotland. We provide training on it, work with others to publish guidance on it, and we collate and publish research about it.

Yesterday, NHS Information Services Division published their annual report (pdf) of service statistics on Scotland’s stop smoking services. These figures are useful, because they let us see how many, and what type of people quit smoking with these (free, through the NHS) services, and how this picture has changed over time. This data release shows that more quit attempts were made through services in 2012 (116,198) than 2011 (112,812), continuing the increasing trend seen in recent years.  Good news.

But the important thing of course is not just how many people ‘attempt’ to quit, it is how many actually do go on to quit. From today’s data, 38% of those who make a quit attempt are still non-smokers at one month (see the graph below). Over time this decreases to 16% at 3 months, and around 6% at one year.

graph of smoking cessation statistics in Scotland

[Image of graph taken from NHS ISD Scotland report.]

Now, a critical view we sometimes hear is ‘well, if only 6% have quit at 12 months, that doesn’t sound like a very good service to me’. You might be tempted to agree with this, but there are several other factors to weigh into the judgement here.

One is that all clients who haven’t been able to be contacted (the green bars in the graph above, nearly 70% at 12 months) are counted as smokers. This probably isn’t the case in reality: many will be non-smokers as a result of the support, but just haven’t been around to receive the 12 month follow-up phone call or didn’t reply to other attempts at contact, such as by letter.

If the success rates in those who were ‘lost to follow-up’ were the same as those contactable, then the overall quit rates at one year would be more like 18%. However, this might be too high – you could pretty reasonably argue that people who weren’t able to be contacted are less likely to be successfully quit than those who were able to be contacted (negative feelings about their lack of quit success meaning they avoided contact with the follow-up service).

In a study of somewhat similar services in England with very comprehensive follow up, researchers found one-year quit outcomes of 15% to 18% (depending on whether you are happy with a ‘self-reported’ quit, or one that has been validated by carbon monoxide). So it seems quite likely the ‘true’ success rates in Scotland are going to be similar – maybe not as high as 18%, but certainly higher than 6%.

Now if you are being (even more) critical, you could say ‘well, even 15% doesn’t sound like a very good success rate to me, if I take antibiotics or go for major surgery I want a success rate of 95% plus, why shouldn’t I get this if I go to a NHS-funded stop smoking service?’

Unfortunately there are no easy answers at this point – the reality is that cigarette smoking is addictive, stopping for good can be difficult, and after a (relatively short) smoking cessation intervention people go back into everyday life where there are many cues that can trigger relapse to smoking again. This is why only around 3% to 5% of ‘unassisted’ quit attempts are successful at one year. However, because the ‘unassisted’ chances of success are (unfortunately) quite low, even stop smoking support that increases one year success rates by what appears to be a quite modest amount, to 15% (though bear in mind this is actually a  four-fold or so increase), is the most effective support we know about. It also turns out that, because of this, when you examine how much it costs the NHS, it works out to be very cost-effective to provide.

 If you are interested in getting advice or assistance to stop smoking in Scotland and giving your quit attempt the best chance of success, have a look at canstopsmoking.com

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2 comments

  1. Of course, you forget to do two things:
    1: Define “quit”. If you mean complete abstinence from Nicotine then my next point probably has no meaning to ASH Scotland (although it patently does for ASH UK). If, by “stop smoking” or “Quit” you mean cease the process of lighting tobacco and inhaling the fumes, then perhaps we can make some progress.

    2: Acknowledge that, according to at least two studies – peer reviewed ones, at that – more than 50% of electronic cigarette users who switch completely have stopped lighting tobacco and inhaling the fumes. They are not Nicotine Abstinent, but they have, by any real definition of the term, “Quit Smoking”.

    Now, that kind of success rate – the removal of 99% or more of the risk of COPD, Lung Cancer and everything else that ASH Scotland should be fighting against (not, mark you, smokers and tobacco companies) – is a damned sight more impressive than ANY of the interventions so far introduced.

    And the really impressive thing? Nobody intervened! The whole e-cig success story has happened without the Tobacco Control Industry getting involved in any way. Consumers have done it themselves. They have chosen, and they have shown that what they have chosen works, and works very well.

    So – and here’s the big question – why doesn’t ASH Scotland support the likes of the Smoke Without Fire campaign? Why doesn’t ASH Scotland come out and say, as ASH UK has, that e-cigs are a good thing, and should be promoted?

  2. Hi David, thanks for the comment.

    In this context ‘quit’ means ‘no longer smoking tobacco cigarettes’. Specifically, the figures discussed in the blog use these (well-established & commonly applied) criteria for exactly what constitutues a ‘quit’.

    On the other point, re: electronic cigarettes being ‘… more impressive than ANY of the interventions so far introduced…’

    In brief, I don’t think your assertion can be made with certainty at this point (though it is of course possible, perhaps even likely). But we should be a bit cautious here because the relatively few prospective (that is, following people’s smoking behaviour through time) clinical studies on electronic cigarettes that exist at present (of which this paper by Polosa & colleagues is probably the most well-known) have quite a lot of limitations.

    The main issues are: 1) the studies are very small, meaning the possibility of fluke findings are pretty high (the history of research is one full of initially positive findings in small studies failing to be replicated in larger ones); and 2) limited or no control groups in these studies (so we can’t quite be certain how many people from the study population would have had a quitting or smoking reduction outcome without the intervention, or if they would have done better or worse if they had what we would usually recommend instead of e-cigarettes).

    The good news is that some of these limitations are being addressed in subsequent research. Polosa & colleagues have conducted a larger follow-up study involving many more people (in an early presentation of this work at a conference, ‘quit’ rates at 12 months were around 10%, which is roughly similar to what you would expect to conventional medicinal nicotine products). Another large trial is ongoing in New Zealand, and intends to compare e-cigarettes directly with medicinal nicotine. This is expected to report results later this year.

    So, while some are convinced of the benefits of e-cigarettes already through their personal experiences (which is fine, of course) – the evidence on whether & in what circumstances e-cigarettes are to be recommended over conventional approaches is actually still at quite an early stage.

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