Successes and Challenges of Implementing Tobacco Dependency Treatment in Health Care Institutions in England

There is a significant body of evidence that delivering tobacco dependency treatment within acute care hospitals can deliver high rates of tobacco abstinence and substantial benefits for both patients and the healthcare system. This evidence has driven a renewed investment in the UK healthcare service to ensure all patients admitted to hospital are provided with evidence-based interventions during admission and after discharge. An early-implementer of this new wave of hospital-based tobacco dependency treatment services is “the CURE project” in Greater Manchester, a region in the North West of England. The CURE project strives to change the culture of a hospital system, to medicalise tobacco dependency and empower front-line hospital staff to deliver an admission bundle of care, including identification of patients that smoke, provision of very brief advice (VBA), protocolised prescription of pharmacotherapy, and opt-out referral to the specialist CURE practitioners. This specialist team provides expert treatment and behaviour change support during the hospital admission and can agree a support package after discharge, with either hospital-led or community-led follow-up. The programme has shown exceptional clinical effectiveness, with 22% of all smokers admitted to hospital abstinent from tobacco at 12 weeks, and exceptional cost-effectiveness with a public value return on investment ratio of GBP 30.49 per GBP 1 invested and a cost per QALY of GBP 487. There have been many challenges in implementing this service, underpinned by the system-wide culture change and ensuring the good communication and engagement of all stakeholders across the complex networks of the tobacco control and healthcare system. The delivery of hospital-based tobacco dependency services across all NHS acute care hospitals represents a substantial step forward in the fight against the tobacco epidemic

Patient survey examining the experience of care of a hospital-based opt-out tobacco dependency treatment service (the CURE Project)

INTRODUCTION: Treating tobacco dependency in patients admitted to hospital is a key priority in the National Health Service long-term plan. This service evaluation assessed the perception, needs and experience of care within an opt-out hospital-based tobacco dependency treatment service (the Conversation, Understand, Replace, Experts and Evidence Base (CURE) team) in North-West England. METHODS: A survey was offered to all eligible patients between 1 July 2020 and 30 September 2020. Eligibility criteria were adult patients identified as an active smoker being approached by the CURE team as part of the standard opt-out service model, on a non-covid ward without a high suspicion of COVID-19 infection and able to read and write in English. RESULTS: 106 completed surveys were evaluated. Participants demonstrated high levels of tobacco dependency with an average of 37 years smoking history and 66% describing the onset of cravings within 30 min of hospital admission. The average number quit attempts in the previous 12 months was 1.3 but only 9% had used the most effective National Institute for Health and Care Excellence (NICE) recommended treatments. 100% felt the opt-out service model was appropriate and 96% stated the treatment and support they had received had prompted them to consider a further quit attempt. 82% of participants rated their experience of care as 9/10 or 10/10. Participants wanted a broad range of support post discharge with the most popular option being with their general practitioner. 66% and 65% of participants would have been interested in a vaping kit as stop smoking intervention and support vaping-friendly hospital grounds respectively. CONCLUSION: These results suggest this hospital-based, opt-out tobacco dependency treatment service delivers high-quality experience of care and meets the needs of the patients it serves. It also highlights the opportunity to enhance outcomes by providing access to NICE recommended most-effective interventions (varenicline, vaping and combination nicotine replacement therapy) and providing flexible, individualised discharge pathways

Understanding the implementation strategy of a secondary care tobacco addiction treatment pathway (The CURE Project) in England: A Strategic Behavioural Analysis

Objectives The Conversation, Understand, Replace, Experts and evidence-based treatment (CURE) project implemented an evidence-based intervention that offers a combination of pharmacotherapy and behavioural support to tobacco-dependent inpatients. Understanding key characteristics of CURE’s implementation strategy, and identifying areas for improvement, is important to support the roll-out of nationwide tobacco dependence services. This study aimed to (1) specify key characteristics of CURE’s exiting implementation strategy and (2) develop theoretical-informed and stakeholder-informed recommendations to optimise wider roll-out. Design and methods Data were collected via document review and secondary analysis of interviews with 10 healthcare professionals of a UK hospital. Intervention content was specified through behaviour change techniques (BCTs) and intervention functions within the Behaviour Change Wheel. A logic model was developed to specify CURE’s implementation strategy and its mechanisms of impact. We explored the extent to which BCTs and intervention functions addressed the key theoretical domains influencing implementation using prespecified matrices. The development of recommendations was conducted over a two-round Delphi exercise. Results We identified six key theoretical domains of influences: ‘environmental context and resources’, ‘goals’, ‘social professional role and identity’, ‘social influences’, ‘reinforcement’ and ‘skills’. The behavioural analysis identified 26 BCTs, 4 intervention functions and 4 policy categories present within the implementation strategy. The implementation strategy included half the relevant intervention functions and BCTs to target theoretical domains influencing CURE implementation, with many BCTs focusing on shaping knowledge. Recommendations to optimise content were developed following stakeholder engagement. Conclusions CURE offers a strong foundation from which a tobacco dependence treatment model can be developed in England. The exiting strategy could be strengthened via the inclusion of more theoretically congruent BCTs, particularly relating to ‘environmental context and resources’. The recommendations provide routes to optimisation that are both theoretically grounded and stakeholder informed. Future research should assess the feasibility/acceptability of these recommendations in the wider secondary-care context