Educational initiatives aimed at promoting self-management in chronic diseases such as diabetes need to be designed with an awareness of the complexity of social and cultural experiences and attitudes in target communities.
In 2000/01, English smoking cessation services provided cost-effective services operating well below the benchmark of pound 20,000 per quality-adjusted life-year saved (QALY) that is used by the National Institute for Clinical Excellence in the United Kingdom.
Objectives: To determine the extent to which UK National Health Service (NHS) smoking cessation services in England reach smokers and support them to quit at four weeks, and to identify which service and area characteristics contribute to observed outcomes. Design: Ordinary least squares regression was used to investigate local smoking outcomes in relation to characteristics of health authorities and their smoking cessation services. Setting: 76 health authorities (from a total of 99) in England from April 2000 to March 2001. Main outcome measures: Reach-number of smokers attending cessation services and setting a quit date as a percentage of the adult smoking population in each health authority. Absolute success-number of smokers setting a quit date who subsequently reported quitting at four weeks (not having smoked between two and four weeks after quit date). Cessation rate-number of smokers who reported quitting at four weeks as a percentage of those setting a quit date. Loss-percentage lost to follow up. Results: A range of service and area characteristics was associated with each outcome. For example, group support proved more effective than one to one interventions in helping a greater proportion of smokers to quit at four weeks. Services based in health action zones were reaching larger numbers of smokers. However, services operating in deprived communities achieved lower cessation rates than those in more prosperous areas. Conclusions: Well developed, evidence based NHS smoking cessation services, reflecting good practice, are yielding positive outcomes in England. However, most of the data are based on self reported smoking status at four weeks. It will be important to obtain validated data about continuous cessation over one year or more in order to assess longer term impact.
As English smoking treatment services developed, lessons were learned that could inform the development of services in other health systems. First, early guidance from government can encourage services to adhere to evidence-based treatment. Secondly, treatment needs to be accessible to smokers and thus there must be a flexible approach to implementation at local level. Thirdly, the availability of nicotine addiction and behavioural therapies should be coordinated to minimize barriers and maximize uptake. Finally, fixed-term funding can exacerbate staff recruitment and retention difficulties and countries establishing treatment services need to consider carefully the initial funding period that is required for stable services to become established within their health systems.
Monitored targets for smoker throughput ensured that services quickly began to treat smokers, but this rapid implementation diverted service staff from devising methods for attracting priority group smokers. Coordinators found reaching priority groups challenging and, particularly in the case of young smokers, would have appreciated clear instructions for this aspect of service implementation. Those implementing services in other countries should consider whether similar targets would be helpful to stimulate service development within their health systems.
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