UK/NI/14-2970Date of preparation: June 2014

Guest speakers: Emma Croghan, Mary Campbell & Sonia Simkins

UKNSCC 2014

Prescribing information can be found at the end of this presentation

Organised and funded by Johnson & Johnson Ltd., owners of

Today’s agenda

1. 15 years on: Stop Smoking Services (SSS), a victim of their own success?

2. Smoking Cessation (SC) in Secondary Care

3. Smoking Cessation in Primary Care

4. Group discussion and Q&A

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The Quitting Edge programme

Quitting Edge (QE) – a long-term initiative to support HCPs and SSSs in providing high quality advice, support & treatment

QE takes a pragmatic approach to share real-life examples and learnings from peers and colleagues across the country

It focuses on the role of engagement and collaboration in helping deliver on the ambitious targets set

HCP - Healthcare Professional3

Emma CroghanDirector of Public Health and Lifestyle Services, North 51

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We know footfall to SSSs is in decline 1

There might be a number of reasons for this

There is a wide variation in footfall and quit rates from service to service1

Why is that?

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What does this mean for SSSs?

Still 10 million smokers out there2

16.6% have tried quitting smoking in the last 3 months3

There is an opportunity here, at both secondary care and primary care level to ‘fish where the fish are’

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How can you make your servicemore visible?

ASK some questions!1. Is it visible to referrers/smokers?2. What do referrers/potential

partners know – and need?

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Who could you work in partnership with to drive footfall?

An interview with Mary Campbell Stop Smoking and Prevention Coordinator, Western Trust, Northern Ireland

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The opportunity in secondary care We know that lots of smokers go into secondary care

each year, in England, approximately 1.6m admissions a year are smoking related among adults of 35 years and over4 – plus all the smokers who go with an ‘unrelated’ condition

In a pilot study comprising 1097 patients, 31% of the hospital population were smokers 5 which is considerably higher than the national average (20%)2

Acting on teachable moments – motivation is fluid

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Emma’s maths

If we assume:20% took the referral, then there would be 320,000 referrals alone from the smoking related admissions group

Every third bed contains a smoker; if 20% take the referral this would mean: A ward of 20 beds at any time at least 6 will be smokers and 1 will take the referral

Therefore: broadly every 100 beds should deliver 5 referrals (minimum) per week on average

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My current role in secondary care

Coordination of smokefree campus implementation

Planning and coordination of stop smoking services

Develop / design care pathways / clinical

management plans / electronic referral

Develop / implement education programmes within

secondary care – e learning

Leader, manager, clinician, research

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Encouraging quitters in acute settings

How can you motivate other HCPs in secondary care to get involved in smoking cessation?Be visible, approachable, helpful Feedback to staff on patients quitting

ChallengesTime constraintsReduced in-patient periodsSkill mixIts everyone’s jobSupport for staff to quitGet families to quit

How do you overcome barriers to providing smoking cessation to secondary care patients?Training specific to each specialism Offer training at each opportunityCO monitoring Mentor clinical staff Make referral easy (ex: electronic referral)Immediate access to pharmacotherapy and behavioural support – PGD Use of NRT

 PGD - Pre-implantation genetic diagnosis  12

Service collaboration with secondary care Seamless service – continuity of care Contacts for services pre, during and post

admission Adequate NRT given on discharge Posters / fliers on services available Leaflets – benefits of quitting, risks of SHS Motivating smokers to quit – individualise

the information / listen to the client

SHS = Second hand smoke 13

Who can you target in secondary care ?

Liaise with HCPs, Managers, HCAs, support staff Hospital admission – “teachable moment” –

professional and moral duty to help smokers to quit

HCA - HealthCare Assistant

Respiratory, acute medical units, antenatal and post natal, outpatient clinics, paediatrics and neonatal units

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3 take-home messages

1. Hospital admission – “teachable moment” – professional and moral duty to help smokers to quit

2. Make every contact count 3. Quit for life improvement

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An interview with Sonia SimkinsPractice Manager, Rowley Healthcare

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What about opportunities in primary care?

30% of quit attempts were triggered by advice from an HCP7

However, many barriers to working in primary care and we need to be able to sell it into the practice

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The UK population saw their GP on average 6.4 times in 2013 6

Emma’s maths

Let’s assume a practice of 5,000 patients We can suppose that 20% of them are smokers (as

per national average smoking prevalence2). This means there are 1,000 smokers in this practice

Let’s assume that out of these 1,000 smokers, 700 visit this practice per year

Finally, let’s assume, 20% of those 700 take up the referral…This would equal 140 referrals to a Stop Smoking Service per year for that practice

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Objectives

Decide as an organisation/practice if helping patients to quit smoking is a priority

Is it a realistic goal? Look at the category of patients!

Is the process manageable from a practice point of view

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Challenges

All staff must be on board with the project for it to be a success

Referral system should be quick and easy to follow for staff and patients

The clinics need to run effectively It is essential there is a good working

relationship with the advising team All staff to be informed about the project and

have access to the information explaining the service

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Success?

Referral forms placed in every clinical room Encouragement from referring staff to ensure

patients are on board with the process!!! Efficient correspondence between the

practice and service provider i.e Q51 Referrals managed efficiently by Practice Staff

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3 take-home messages

1. Referral system2. Efficient correspondence

3. Encouragement from referring staff

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Discussion and Q&A

What do you think?

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QE Resource Stick

Features valuable insights from the smoking cessation field including:

Tips on understanding and engaging smokers from different backgrounds

Information on treatment interventions such as Nicotine Replacement Therapy

Guidance on quit strategies and harm reduction A step by step guide to collaborating with peers

It is available free

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References

1. Statistics on NHS Stop Smoking Services: England April 2012 – March 2013. Published 30 October 2013

2. ASH Smoking Statistics Factsheet. October 20133. R. West. Smoking Toolkit Study – Trends in electronic cigarette use in

England. Updated 21 March 20144. HSCIC. Statistics on smoking: England, 2013. Published 15 August 20135. NCSCT. Stop smoking interventions in secondary care. August 20126. NHS England Analytical Service. Improving GP – a call to action, Evidence

Pack. August 2013/147. R. West et al. Key findings from the Smoking Toolkit Study. 2012

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Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported

to McNeil Products Limited on 01344 864 042

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Nicorette® Invisi Patch Prescribing InformationPresentation: Transdermal delivery system available in 3 sizes (22.5, 13.5 and 9cm2) releasing 25mg, 15mg and 10mg of nicotine respectively over 16 hours. Uses: Nicorette Invisi Patch relieves and/or prevents craving and nicotine withdrawal symptoms associated with tobacco dependence. It is indicated to aid smokers wishing to quit or reduce prior to quitting, to assist smokers who are unwilling or unable to smoke, and as a safer alternative to smoking for smokers and those around them.  Nicorette Invisi Patch is indicated in pregnant and lactating women making a quit attempt. If possible, Nicorette Invisi Patch should be used in conjunction with a behavioural support programme.   Dosage: It is intended that the patch is worn through the waking hours (approximately 16 hours) being applied on waking and removed at bedtime.  Smoking Cessation: Adults (over 18 years of age): For best results, most smokers are recommended to start on 25 mg / 16 hours patch (Step 1) and use one patch daily for 8 weeks.  Gradual weaning from the patch should then be initiated.  One 15 mg/16 hours patch (Step 2) should be used daily for 2 weeks followed by one 10 mg/16 hours patch (Step 3) daily for 2 weeks.  Lighter smokers (i.e. those who smoke less than 10 cigarettes per day) are recommended to start at Step 2 (15 mg) for 8 weeks and decrease the dose to 10 mg for the final 4 weeks.   Those who experience excessive side effects with the 25 mg patch (Step 1), which do not resolve within a few days, should change to a 15 mg patch (Step 2).  This should be continued for the remainder of the 8 week course, before stepping down to the 10 mg patch (Step 3) for 4 weeks.  If symptoms persist the advice of a healthcare professional should be sought. Adolescents (12 to 18 years):  Dose and method of use are as for adults however, recommended treatment duration is 12 weeks.  If longer treatment is required, advice from a healthcare professional should be sought. Smoking Reduction/Pre-Quit: Smokers are recommended to use the patch to prolong smoke-free intervals and with the intention to reduce smoking as much as possible.  Starting dose should follow the smoking cessation instructions above i.e. 25mg (Step 1) is suitable for those who smoke 10 or more cigarettes per day and for lighter smokers  are recommended to start at Step 2 (15 mg).  Smokers starting on 25mg patch should transfer to 15mg patch as soon as cigarette consumption reduces to less than 10 cigarettes per day.   A quit attempt should be made as soon as the smoker feels ready. When making a quit attempt smokers who have reduced to less than 10 cigarettes per day are recommended to continue at Step 2 (15 mg) for 8 weeks and decrease the dose to 10 mg (Step 3) for the final 4 weeks. Temporary Abstinence: Use a Nicorette Invisi Patch in those situations when you can’t or do not want to smoke for prolonged periods (greater than 16 hours).  For shorter periods then an alternative intermittent dose form would be more suitable (e.g. Nicorette inhalator or gum).  Smokers of 10 or more cigarettes per day are recommended to use 25mg patch and lighter smokers are recommended to use 15mg patch.Contraindications: Hypersensitivity. Precautions: Unstable cardiovascular disease, diabetes mellitus, renal or hepatic impairment, phaeochromocytoma or uncontrolled hyperthyroidism, generalised dermatological disorders. Angioedema and urticaria have been reported.  Erythema may occur. If severe or persistent, discontinue treatment. Stopping smoking may alter the metabolism of certain drugs. Transferred dependence is rare and less harmful and easier to break than smoking dependence. May enhance the haemodynamic effects of, and pain response, to adenosine.  Keep out of reach and sight of children and dispose of with care. Pregnancy and lactation: Only after consulting a healthcare professional. Side effects: Very common: itching.  Common: headache, dizziness, nausea, vomiting, GI discomfort; Erythema. Uncommon: palpitations, urticaria. Very rare: reversible atrial fibrillation. See SPC for further details. NHS Cost: 25mg packs of 7: (£9.97); 25mg packs of 14: (£16.35); 15mg packs of 7: (£9.97); 10mg packs of 7: (£9.97). Legal category: GSL.  PL holder: McNeil Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG. PL numbers: 15513/0161; 15513/0160; 15513/0159.  Date of preparation: Feb 2012

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Nicorette® QuickMist Mouthspray Prescribing InformationPresentation: oromucosal spray containing 13.2ml solution. Each 0.07 ml contains 1 mg nicotine, corresponding to 1 mg

nicotine/spray dose. Uses: Relieves and/or prevents craving and nicotine withdrawal symptoms associated with tobacco dependence. It is indicated to aid smokers wishing to quit or reduce prior to quitting, to assist smokers who are unwilling or unable to smoke, and as a safer alternative to smoking for smokers and those around them. It is indicated in pregnant and lactating women making a quit attempt. Dosage: Adults and Children over 12 years of age: The patient should make every effort to stop smoking completely during treatment with Nicorette QuickMist. One or two sprays to be used when cigarettes normally would have been smoked or if cravings emerge. If after the first spray cravings are not controlled within a few minutes, a second spray should be used. If 2 sprays are required, future doses may be delivered as 2 consecutive sprays. Most smokers will require 1-2 sprays every 30 minutes to 1 hour. Up to 4 sprays per hour may be used; not exceeding 2 sprays per dosing episode and 64 sprays in any 24-hour period. Nicorette QuickMist should be used whenever the urge to smoke is felt or to prevent cravings in situations where these are likely to occur. Smokers willing or able to stop smoking immediately should initially replace all their cigarettes with the Nicorette QuickMist and as soon as they are able, reduce the number of sprays used until they have stopped completely. When making a quit attempt behavioural therapy, advice and support will normally improve the success rate. Smokers aiming to reduce cigarettes should use the Mouthspray, as needed, between smoking episodes to prolong smoke-free intervals and with the intention to reduce smoking as much as possible. Contraindications: Children under 12 years and Hypersensitivity. Precautions: Unstable cardiovascular disease, diabetes mellitus, G.I disease, uncontrolled hyperthyroidism, phaeochromocytoma, hepatic or renal impairment. Stopping smoking may alter the metabolism of certain drugs. Transferred dependence is rare and both less harmful and easier to break than smoking dependence. May enhance the haemodynamic effects of, and pain response to, adenosine. Keep out of reach and sight of children and dispose of with care. Pregnancy & lactation: Only after consulting a healthcare professional. Side effects: Very common: dysgeusia, headache, hiccups, nausea and vomiting symptoms, dyspepsia, oral soft tissue pain and paraesthesia, stomatitis, salivary hypersecretion, burning lips, dry mouth and/or throat. Common: dizziness, vomiting, flatulence, abdominal pain, diarrhoea, , throat tightness, fatigue, chest pain and discomfort, toothache. Other: palpitations, atrial fibrillation, dyspnoea, bronchospasm . See SPC for further details. NHS Cost: 1 dispenser pack £12.12, 2 dispenser pack £19.14. Legal category: GSL. PL holder: McNeil Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG. PL number: 15513/0357. Date of preparation: October 2013

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Nicorette ® 15 mg Inhalator Prescribing Information

Presentation: Inhalation cartridge containing 15mg nicotine for oromucosal use via a mouthpiece. Uses: Relieves and/or prevents craving and nicotine withdrawal symptoms associated with tobacco dependence. It is indicated to aid smokers wishing to quit or reduce prior to quitting, to assist smokers who are unwilling or unable to smoke, and as a safer alternative to smoking for smokers and those around them. It is indicated in pregnant and lactating women making a quit attempt. Dosage: Adults and Children over 12 years of age:  Nicorette Inhalator should be used whenever the urge to smoke is felt or to prevent cravings in situations where these are likely to occur.   Smokers willing or able to stop smoking immediately should initially replace all their cigarettes with the Inhalator and as soon as they are able, reduce the number of cartridges used until they have stopped completely.  Smokers aiming to reduce cigarettes should use the Inhalator, as needed, between smoking episodes to prolong smoke-free intervals and with the intention to reduce smoking as much as possible.  As soon as they are ready smokers should aim to quit smoking completely.  Maximum of 6 cartridges per day should be used.  When making a quit attempt behavioural therapy, advice and support will normally improve the success rate. Those who have quit smoking, but are having difficulty discontinuing their Inhalator are recommended to contact their pharmacist or doctor for advice.  Contraindications: Children under 12 years and Hypersensitivity. Precautions: Unstable cardiovascular disease, diabetes mellitus, G.I disease, uncontrolled hyperthyroidism, phaeochromocytoma, hepatic or renal impairment, chronic throat disease, obstructive lung disease or bronchospastic disease. Stopping smoking may alter the metabolism of certain drugs. Transferred dependence is rare and both less harmful and easier to break than smoking dependence. May enhance the haemodynamic effects of, and pain response to, adenosine.  Keep out of reach and sight of children and dispose of with care. Best used at room temperature. Pregnancy & lactation: Only after consulting a healthcare professional. Side effects: Cough, irritation of throat and mouth, headache, nasal congestion, nausea, vomiting, hiccups, palpitations, GI discomfort, dizziness, reversible atrial fibrillation. See SPC for further details. NHS Cost: 4 cartridge pack £4.14, 20 cartridge pack £14.03. 36 cartridge pack  £22.33. Legal category: GSL. PL holder: McNeil Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG.  PL number: 15513/0358. Date of preparation: June 2011

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