Neighbourhood deprivation and Stop Smoking Service outcomes

Leonie Brose1, Volker Behrends2

1Addictions, UK Centre for Tobacco and Alcohol Studies, Institute of Psychiatry, KCL

2 Department of Surgery and Cancer, Imperial College

Acknowledgements

Professor Robert West Dr Andy McEwen

Everyone at the NCSCT who helped with the data provision North51

All service managers who agreed to share data

My post is funded by the UK Centre for Tobacco and Alcohol Studies. Funding from the Medical Research Council, British Heart Foundation, Cancer Research UK, Economic and Social Research Council and the National Institute for Health Research under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged (MR/K023195/1).

• Social injustice kills • England: Gap in life expectancy 17 years• Other negative effects, unaffordable to ignore Approaches– Universal health care – Address health behaviours

• Smoking particular determinant of inequality

Deprivation and smoking

• Not less likely to attempt to stop, but attempts less successful e.g. 2, 3

• In stop smoking services (2001-03): ‘Rather than quitting smoking, disadvantaged smokers quit treatment’ 4

Smoking and cessation England 1 Most deprived Least deprived

Smoking men % 33 14

Smoking women % 26 10

Ever smokers who quit % 50 75

1 Office for National Statistics, 2014. 2 Kotz et al, 2009. 3 Reid et al, 2010. 4 Hiscock et al, 2011

Questions

1. To what extent is neighbourhood deprivation associated with – loss to follow-up – success of quit attempts while taking into account other demographic or treatment characteristics?

2. Can difference in success be explained by loss to follow-up?

3. Does neighbourhood deprivation add anything above and beyond other indicators of deprivation?

How we measured deprivation

• Index of multiple deprivation, IMD• 38 indicators in seven domains

– Income– Employment– Health and disability– Education and Training– Barriers to housing & services– Living environment– Crime

• Available across England for Lower Super Output Areas – LSOAs: neighbourhoods consisting of about 1500 residents

• Other indicators – Occupation (NS-SEC)– Education – IMDs for larger areas, e.g. service

Sample

• 555,744 treatment episodes from 2009 to 2012– Excludes 14% of initial sample: ongoing treatment,

telephone support, prisoners, incomplete postcodes

• Linked to Index of Multiple Deprivation for neighbourhood (LSOA) using postcode

• Split into 10 groups of different levels of deprivation relative to all English LSOAs

Measures – associations?

Outcomes• Loss to 4-week follow-up• Self-reported 4-week success• 4-week CO-validated success

rates (lost=no)

Demographics• Age• Gender• Heaviness of smoking (18%)

Intervention• Medication• Type• Setting• First or later attempt with stop smoking service

Deprivation • Index of Multiple Deprivation, 10 groups• Occupation NS-SEC: employed v not employed• Exemption from prescription charges

1 2 3 4 5 6 7 8 9 10 Average0

10

20

30

40

50

60

70

Clients and outcomesClients Lost to follow-up Self-reported 4-week quit CO-validated 4-week quit

IMD Rank decile

%

Most deprived Least deprived

1 2 3 4 5 6 7 8 9 10 Average0

10

20

30

40

50

60

DemographicsAge Men

IMD Rank decile

Year

s/%

Most deprived Least deprived

1 2 3 4 5 6 7 8 9 10 Average0

10

20

30

40

50

60

70

80

90

100

Intervention1st episode 1-1 support Specialist clinic

IMD Rank decile

%

Most deprived Least deprived

1 2 3 4 5 6 7 8 9 10 Average0

5

10

15

20

25

30

35

40

45Combi NRT Varenicline Single NRT None

IMD Rank decile

%

Most deprived Least deprived

None/unknown 9.6%

Single NRT 33.4%

Combination NRT 26.4%

Varenicline 26.4%

Medication

1 2 3 4 5 6 7 8 9 100

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

5.5

6

0

5

10

15

20

25

3.55

2.98

20.5

13.1

Dependence (Heaviness of Smoking Index)Mean score % Recorded

IMD Rank decile

Mea

n sc

ore

%

Most deprived Least deprived

vs 1st timeEach step from more to less deprivation

vs 1-1 vs specialist clinic

Does loss explain differences in success?

• Lost usually treated as not successful - Loss to follow-up closely linked to success rates

• Only completed episodes (416,436 episodes):– Association success and deprivation only very

slightly smaller (OR=1.03, 95% CI: 1.03 to 1.03, p<0.001)

No

1 2 3 4 5 6 7 8 9 10 Average0

10

20

30

40

50

60

70

80

90

Individual deprivationEmployed Pays for prescriptions

IMD Rank decile

%

Most deprived Least deprived

1 2 3 4 5 6 7 8 9 10 Average1

11

21

31

41

51

61

71

81

91

101

111

121

131

141

151

Service-level deprivation

Neighbourhood IMD Rank decile

Serv

ice

Rank

Most deprived Least deprived

Does neighbourhood deprivation add anything to other indicators?

• Added individual indicators of deprivation and service-level deprivation to model

• All closely related, but– Neighbourhood deprivation remained associated with

reduced follow-up and quit success– Unemployment, exemption and service-level deprivation

also associated with worse outcomes Yes

Conclusions

• Services continue to support many disadvantaged smokers• Follow-up rates and success rates decrease with

deprivation• Some characteristics that are associated with reduced

success also associated with deprivation – Additional hurdles to stopping– Do not explain difference in outcomes

• Limitations– Data collected prior to 2013 – Repeated recording of the same individual

Some remaining questions

• Why?• Background quit rates?• Those returning may need more/different support• What is the full picture on dependence?• What causes difference in medication use across deprivation?• Recording practice pharmacies?

Thank you

Leonie.brose@kcl.ac.uk

Complete Follow-up Quit Success

OR 95% CI OR 95% CIIMD decile 1.05 1.05 1.05 1.04 1.04 1.05Men 0.97 0.96 0.99 1.04 1.03 1.05Age (10 year increase) 1.24 1.23 1.24 1.20 1.20 1.21Later episode compared with first episode 1.09 1.08 1.11 0.95 0.94 0.96Medication, reference none

Single NRT 1.12 1.10 1.14 1.49 1.45 1.52Bupropion 1.54 1.44 1.65 1.91 1.79 2.03Combination NRT 1.61 1.58 1.65 2.30 2.24 2.35Varenicline 1.72 1.68 1.76 2.92 2.85 2.99

Intervention type, reference 1:1 Group 1.65 1.59 1.71 1.64 1.60 1.69Drop-in 1.14 1.12 1.17 0.92 0.90 0.94Other 1.27 1.19 1.35 1.18 1.12 1.25

Intervention setting, reference specialist service Primary Care 0.66 0.65 0.67 0.81 0.80 0.82Pharmacy 0.60 0.59 0.61 1.06 1.04 1.07Other 1.14 1.09 1.18 0.93 0.90 0.96