NHS Hospitals showing very slow progress on helping people quit smoking, with staff lacking training and the tools to help patients who smoke.

To eliminate tobacco-related lung disease in the UK, BTS has for many years recommended providing effective stop smoking services to patients while they are admitted to hospital; a recommendation later embraced by the NHS in the Long Term Plan which aims for all smokers admitted to hospital to be offered NHS-funded tobacco treatment services by 2023/4.

To track progress on these recommendations, BTS uses its smoking cessation audit to periodically look at whether hospitals had an adequately led and staffed smoking cessation service, and at the advice and support given to patients to quit smoking if they wanted to. The audit also checks if hospitals are practically prepared to help patients quit, including by enforcing fully smoke-free grounds and by stocking addiction-relieving medications.

The findings of the audit, involving 125 hospitals and 13,647 admitted patients, include:

• Around 3 in 4 (77%) patients were asked if they smoked, similarly to 2016. This means over 20% of patients still do not have their smoking status recorded in their medical notes.
•  Less than half of smokers (44%) were asked if they would like help to quit, up from 28%, and only 1 in 8 were then referred to a hospital or community-based smoking cessation service.
•  38% hospitals had a hospital-based smoking cessation service, down from 56%.
•  Only 15% hospitals offered their outpatients reliable access to a smoking cessation service, down from 34%.
•  Half of frontline healthcare staff (50%) were offered regular smoking cessation training, up from 44%.
•  28% of hospitals had designated smoking areas, down from 41%. This means 72% hospitals have now smoke free grounds. However, in 56% of these, smoking restrictions were rarely or not at all enforced.
•  Nicotine Replacement Therapy (NRT) was offered to just under 1 in 3 (31%) current smokers, up from 1 in 20, but only 1 in 2 (53%) trusts had the (smoking) addiction-relieving drug Varenicline on their list of agreed and stocked drugs.

The 2019 audit shows that the NHS is still missing many opportunities to help patients to quit smoking and multiple generations of smokers continue to miss out on the indisputable benefits of stopping smoking. More progress is needed, and BTS is urging NHS leadership to use the current reconfiguration of healthcare prompted by COVID-19 pandemic to embed properly funded and organised smoking cessation in all its reformed services, making best use of all the new digital solutions and innovations that resulted from dealing with the pandemic.

Dr Zaheer Mangera, Audit Lead and Chair of the BTS Tobacco Advisory Group, said: “While it is good to see that almost half of smokers are now asked if they want help to quit and that there are more stop smoking specialists in the NHS, hospitals are often not properly equipped to follow up on their own advice.

 “Adherence to national standards continues to be poor and the aims of the NHS Long Term Plan, which aspires to offer support to every single smoker that spends one night in hospital, is currently not achievable. Any improvement we see is against a very low background; the majority of patients are still not being referred. 

 “We need more staff trained in smoking cessation, better structures to identify smokers, improved referral procedures, and we need to make sure we use all the tools at the NHS’ disposal, such as nicotine replacement products and medications that help smokers overcome their nicotine addiction as part of a comprehensive hospital based smoking cessations service"

Despite some progress was made since 2016, more is needed, and BTS is recommending that, by 2023-4:

• Referral to on site NHS smoking cessation services must become the norm for all patients who smoke. This can be achieved mandating the recording of smoking status. Automating the identification and clinical coding of smokers using digital records can assist in this goal.
• NRT should be routinely offered as a prescription to help patients with their tobacco dependence, which can help smokers to remain abstinent during their stay and beyond. In this case too, automation and digital records can support healthcare professionals in this endeavour.
• Trust boards must take immediate steps and be held accountable to regulators in ensuring leadership and resources are in place to offer stopping smoking support to all smokers that spend one night or more in hospital. As part of this, all trusts should:
  • Appoint a dedicated clinical lead for smoking cessation, invest in hospital-wide smoking cessation practitioners, but also develop leadership in nursing, service provision, pathway development, and delivery and training.
  • Ensure all front-line staff have a minimal level of competence in smoking cessation, offering additional support to those that want to upskill further in the area.
  • Ensure smoking cessation practitioners are in place and have access to a comprehensive range of pharmacotherapy to support patients to stop smoking while at the hospital.
  • Establishing and enforce completely smoke free grounds. This is essential to create the right culture for staff, patients and visitors.

Dr Alison Cook, chair of the Taskforce for Lung Health, said, "People who smoke are three times more likely to quit when getting support from a specialist service, so it is deeply disappointing to see that the number of people with access to the support they so desperately need to quit smoking is actually dropping.

“For too long, smoking has continued to play a big part in increasing health inequalities and causing lung disease. It is high time that all healthcare professionals are trained in giving very brief advice, and it is now absolutely crucial that sufficient funding is made available to increase the number of hospitals actively offering support to smokers, if the government is to meet its goal of becoming smoke free by 2030.”

Dr Mangera has also published an interview in Respiratory Futures about the audit.