Are NHS Stop Smoking Services being accessed fairly in Gateshead? Andy Billett, Public Health...

Are NHS Stop Smoking Services being

accessed fairly in Gateshead?

Andy Billett, Public Health Analyst

NHS South of Tyne and Wear

Why support people to quit?

Why support people to quit?• 2008/09 cost per 4 week quitter £210

(England average), £265 for Gateshead• Estimated cost of £200 to £900 per life

year gained1

• Average cost of a range of medical interventions £17,000 per life year gained1

1. Parrott S, Godfrey C et al (1998) Guidance for Commissioners on the Cost Effectiveness of Smoking Cessation Interventions, Thorax 1998 December; 53 (Suppl. 5):S32-S37

Why support people to quit• 170 deaths each year in Gateshead due to

lung cancer• 60 more deaths than would be expected if

mortality rate same as for England• 4,600 people (2%) diagnosed with respiratory

disease. True prevalence estimated at twice this level.

• Prevalence (diagnosed) across England 1.5%

Reduce health inequalities• Ethical considerations• Accessing groups where

more people smoke, increase numbers, meet service level performance targets

• Inequalities performance targets

Why support people to quit?

Life Expectancy Gap Between Gateshead and England among Males

0%

20%

40%

60%

80%

100%

Male

19%All Circulatory Diseases(74% of which CHD)

28% All Cancers(58% of which lung cancer)

9% External causes of injury (0% RTAs, 0% suicide)

17% Respiratory(68% of which COPD)

3% Deaths under 28 days

20% Digestive(53% of which cirrhosis)

3% Other

Reduce inequalties through “fair” access

• What is “fair” access?• Access to services in proportion to need• E.g. if 30% of adult men smoke, 20% of

women smoke, more men than women should be using the Stop Smoking Service

• Measured by “service users per 1,000 smokers”

Smoking behaviour in GatesheadMen 18-55

Women 18-24& 35-55

Estimated 14% BME adults smoke, 26% white adults

Felling (38%),High Fell (38%)

Gateshead 26% adults smoke, England 22%

http://images.google.co.uk/imgres?imgurl=http://dreamsandfacts.com/wp-content/uploads/2009/08/male_symbol.png&imgrefurl=http://dreamsandfacts.com/2009/08/man-and-yang/male_symbol/&usg=__msQVEM4rnMDuyuyqsJH6xZ8I3jY=&h=299&w=297&sz=9&hl=en&start=1&um=1&tbnid=EKeoodz-frQbTM:&tbnh=116&tbnw=115&prev=/images%3Fq%3Dmale%2Bsymbol%26hl%3Den%26um%3D1

http://images.google.co.uk/imgres?imgurl=http://societies.dsu.ca/DalOUT/photos/flagssymbols/female/&imgrefurl=http://societies.dsu.ca/DalOUT/resources/symbolsdoc/document_view%3Fmonth:int%3D11%26year:int%3D2008&usg=__EaQFt3g-GJPlNfRSG84PSKCQwnQ=&h=600&w=384&sz=11&hl=en&start=4&um=1&tbnid=9atdO9t5xOG2CM:&tbnh=135&tbnw=86&prev=/images%3Fq%3Dfemale%2Bsymbol%26hl%3Den%26sa%3DG%26um%3D1

Dividing up the population

• Age and gender

• Ethnic group

• Area (ward) of residence

• Level of social/economic disadvantage

• Mosaic Group and Type

• Pregnant women

Measuring fair delivery• Rate of access, service users setting a

quit date per 1,000 smokers• Percentage of service users who set a

quit date successfully quitting at 4 weeks

• Percentage of service users who set a quit date who are lost to follow-up

How many smokers?How many quitters?

• 2008, Gateshead, survey suggests 26% of adults smoke

• Estimated 41,000 adult smokers (16+)

• 2,800 people set quit date in 2007/08

• 1,200 successful quitters at 4 weeks

• 41% quit rate

How many stay quit?• 3% of smokers quit at 4 weeks each

year• 1% of smokers (0.25% of all adults)

remain quit at 1 year?– Evidence says 20%-30% remain quit at 1

year

• Prevalence in Gateshead 1996-2008 (31% to 26%) has changed at rate of 0.4% each year

Fair access?

NHS Stop Smoking Services - access rate per 1,000 smokers ages 16 and over with 95% confidence limits

0

20

40

60

80

100

120

Gateshead SouthTyneside

Sunderland South of Tyneand Wear

England

Acc

ess

ra

te p

er

1,0

00

sm

oke

rs

Gateshead South Tyneside Sunderland South of Tyne and Wear England

Rate of access

Access by genderRate of access of NHS Stop Smoking Service in

Gateshead in 2007/08 per 1,000 smokers by gender

0

25

50

75

100

female male

Age band (years)

Ra

te o

f acc

ess

pe

r 1

,00

0 s

mo

kers

female male

Access by age and

gender

Low rates of access among young men – compare with young women

Rate of access of NHS Stop Smoking Service in Gateshead in 2007/08 per 1,000 smokers by age and

gender

0

40

80

120

160

200

16-24 25-34 35-44 45-54 55-64 65-74 75+

Age band (years)

Ra

te o

f acc

ess

pe

r 1

,00

0

smo

kers

female male

Access by ethnic

group

12 non-white British service users in 2007/08 – a need to attract 50 clients from this group for fair representation

Rate of access of Stop Smoking Services in Gateshead in 2007/08 by broad ethnic group

0

10

20

30

40

50

60

70

80

White All BME groups

Rat

e of

acc

ess

per

1,00

0 sm

oker

s

Access by level of disadvantage

Rate of access of Stop Smoking Services per 1,000 smokers by socioeconomic

group, Gateshead 2007/08

0

20

40

60

80

20

% m

ost

disa

dva

nta

ge

da

rea

s in E

ng

lan

d

20

%-3

9%

40

%-5

9%

60

%-7

9%

20

% m

ost

ad

van

tag

ed

are

as in

En

gla

nd

Socioeconomic disadvantage

Acce

ss rate

pe

r 1,0

00

smo

kers

Only 3% of smokers in this group

Access by w

ard of residence

Wards with low access rates per 1,000 smokers (Gateshead, 70)

• Crawcrook & Greenside (24)• Low Fell (39)• Dunston Hill and Whickham E. (40)• Lamesley (43)• Winlaton and High Spen (45)• Birtley (46)

Access by w

ard of residence

South

Central

Inner West

EastWestWardley andWardley andWardley andWardley andWardley andWardley andWardley andWardley andWardley andLeam LaneLeam LaneLeam LaneLeam LaneLeam LaneLeam LaneLeam LaneLeam LaneLeam Lane

BirtleyBirtleyBirtleyBirtleyBirtleyBirtleyBirtleyBirtleyBirtley

BlaydonBlaydonBlaydonBlaydonBlaydonBlaydonBlaydonBlaydonBlaydonBridgesBridgesBridgesBridgesBridgesBridgesBridgesBridgesBridges

Chopwell and Rowlands GillChopwell and Rowlands GillChopwell and Rowlands GillChopwell and Rowlands GillChopwell and Rowlands GillChopwell and Rowlands GillChopwell and Rowlands GillChopwell and Rowlands GillChopwell and Rowlands GillChowdeneChowdeneChowdeneChowdeneChowdeneChowdeneChowdeneChowdeneChowdene

Crawcrook and GreensideCrawcrook and GreensideCrawcrook and GreensideCrawcrook and GreensideCrawcrook and GreensideCrawcrook and GreensideCrawcrook and GreensideCrawcrook and GreensideCrawcrook and Greenside

DeckhamDeckhamDeckhamDeckhamDeckhamDeckhamDeckhamDeckhamDeckham

Dunston and TeamsDunston and TeamsDunston and TeamsDunston and TeamsDunston and TeamsDunston and TeamsDunston and TeamsDunston and TeamsDunston and Teams

Dunston Hill and Whickham EastDunston Hill and Whickham EastDunston Hill and Whickham EastDunston Hill and Whickham EastDunston Hill and Whickham EastDunston Hill and Whickham EastDunston Hill and Whickham EastDunston Hill and Whickham EastDunston Hill and Whickham East

FellingFellingFellingFellingFellingFellingFellingFellingFelling

High FellHigh FellHigh FellHigh FellHigh FellHigh FellHigh FellHigh FellHigh Fell

LamesleyLamesleyLamesleyLamesleyLamesleyLamesleyLamesleyLamesleyLamesley

Low FellLow FellLow FellLow FellLow FellLow FellLow FellLow FellLow Fell

Pelaw and HeworthPelaw and HeworthPelaw and HeworthPelaw and HeworthPelaw and HeworthPelaw and HeworthPelaw and HeworthPelaw and HeworthPelaw and Heworth

Ryton, Crookhill and StellaRyton, Crookhill and StellaRyton, Crookhill and StellaRyton, Crookhill and StellaRyton, Crookhill and StellaRyton, Crookhill and StellaRyton, Crookhill and StellaRyton, Crookhill and StellaRyton, Crookhill and Stella

SaltwellSaltwellSaltwellSaltwellSaltwellSaltwellSaltwellSaltwellSaltwellWhickham NorthWhickham NorthWhickham NorthWhickham NorthWhickham NorthWhickham NorthWhickham NorthWhickham NorthWhickham North

Whickham South and SunnisideWhickham South and SunnisideWhickham South and SunnisideWhickham South and SunnisideWhickham South and SunnisideWhickham South and SunnisideWhickham South and SunnisideWhickham South and SunnisideWhickham South and Sunniside

Winlaton and High SpenWinlaton and High SpenWinlaton and High SpenWinlaton and High SpenWinlaton and High SpenWinlaton and High SpenWinlaton and High SpenWinlaton and High SpenWinlaton and High Spen

Rate of access of NHS Stop Smoking Services per 1,000Rate of access of NHS Stop Smoking Services per 1,000Rate of access of NHS Stop Smoking Services per 1,000Rate of access of NHS Stop Smoking Services per 1,000Rate of access of NHS Stop Smoking Services per 1,000Rate of access of NHS Stop Smoking Services per 1,000Rate of access of NHS Stop Smoking Services per 1,000Rate of access of NHS Stop Smoking Services per 1,000Rate of access of NHS Stop Smoking Services per 1,000smokers 2007/08 - wards compared with Gateshead averagesmokers 2007/08 - wards compared with Gateshead averagesmokers 2007/08 - wards compared with Gateshead averagesmokers 2007/08 - wards compared with Gateshead averagesmokers 2007/08 - wards compared with Gateshead averagesmokers 2007/08 - wards compared with Gateshead averagesmokers 2007/08 - wards compared with Gateshead averagesmokers 2007/08 - wards compared with Gateshead averagesmokers 2007/08 - wards compared with Gateshead average

Significantly lower at 95% confidence (24 to <57)Significantly lower at 95% confidence (24 to <57)Significantly lower at 95% confidence (24 to <57)Significantly lower at 95% confidence (24 to <57)Significantly lower at 95% confidence (24 to <57)Significantly lower at 95% confidence (24 to <57)Significantly lower at 95% confidence (24 to <57)Significantly lower at 95% confidence (24 to <57)Significantly lower at 95% confidence (24 to <57)Lower (57 to <71)Lower (57 to <71)Lower (57 to <71)Lower (57 to <71)Lower (57 to <71)Lower (57 to <71)Lower (57 to <71)Lower (57 to <71)Lower (57 to <71)Higher (71 to <90)Higher (71 to <90)Higher (71 to <90)Higher (71 to <90)Higher (71 to <90)Higher (71 to <90)Higher (71 to <90)Higher (71 to <90)Higher (71 to <90)Significantly higher at 95% confidence (90 to 110)Significantly higher at 95% confidence (90 to 110)Significantly higher at 95% confidence (90 to 110)Significantly higher at 95% confidence (90 to 110)Significantly higher at 95% confidence (90 to 110)Significantly higher at 95% confidence (90 to 110)Significantly higher at 95% confidence (90 to 110)Significantly higher at 95% confidence (90 to 110)Significantly higher at 95% confidence (90 to 110)

Rate of access of Stop Smoking Services in Gateshead by Mosaic Group

0 20 40 60 80 100 120

People living in rural areas far from urbanisation* (pop.2224)

Independent older people with relatively active lifestyles(pop. 6969)

Older people living in social housing with high care needs(pop. 8958)

Upwardly mobile families living in homes bought from sociallandlords (pop. 17700)

Low income families living in estate based social housing(pop. 39023)

People living in social housing with uncertain employment indeprived areas (pop. 14452)

Educated, young, single people living in areas of transientpopulations* (pop. 941)

Close-knit, inner city and manufacturing town communities(pop. 31949)

Older families living in suburbia (pop. 23022)

Younger families living in newer homes (pop. 12327)

Career professionals living in sought after locations (pop.3596)

Mo

saic

Gro

up

Rate of access per 1,000 smokers

Access by M

osaic

® group

Gateshead average rate of access = 70 per 1,000 smokers* Number of service users <5 in these groups

Under-represented Mosaic typesType Description

15 Senior white collar workers on verge of financially secure retirement (5,000 pop. in Gateshead)

18 Inter war suburbs many with less strong cohesion than they originally had (5,000 pop. in Gateshead)

22 Comfortably off manual workers living in spacious inexpensive private houses (6,000 pop. in G’head)

24 Low income families living in cramped Victorian terraced housing in inner city locations (14,000)

Typ

e 24

- Low

inco

me

families livin

g in

cram

ped

Victoria

n terraced h

ousin

g

Where do these people live?

Pregnant women

• What proportion of women smoke during pregnancy?

• 26% of all adults smoke in Gateshead

Pregnant women• 20% of women in Gateshead smoke at time

of delivery, more at booking of maternity services

• 14% across England• 2,200 births p.a., more than 440 smokers• 163 pregnant women set quit date, 2007/08• 370 per 1,000 smokers (70 average)

Equal chance of success?

Quit Rates

NHS Stop Smoking Services - % of service users successfully quitting at four weeks with 95% confidence limits

0

10

20

30

40

50

60

Gateshead South Tyneside Sunderland South of Tyneand Wear

England

% s

ucc

ess

fully

qu

ittin

g a

t fo

ur

we

eks

t


Quit rates• All adults 41%, females 40%, males 43%

• Quit rates rise with age–16-24 years 30%–55-74 years 50%

• Among BME groups? – don’t know• Pregnant women 41% - same as overall

average

Quit Rates

• Gateshead average 41%

• Felling 31% (41 out of 133)

• Birtley 68% (36 out of 53)

• “People living in social housing with uncertain employment in deprived areas” (Mosaic Group F) quit rate 36%

Where do these people live

South

Central

Inner West



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Proportion of NHS Stop Smoking Service users successfullyProportion of NHS Stop Smoking Service users successfullyProportion of NHS Stop Smoking Service users successfullyProportion of NHS Stop Smoking Service users successfullyProportion of NHS Stop Smoking Service users successfullyProportion of NHS Stop Smoking Service users successfullyProportion of NHS Stop Smoking Service users successfullyProportion of NHS Stop Smoking Service users successfullyProportion of NHS Stop Smoking Service users successfullyquitting at 4 weeks, wards compared with Gateshead average 2007/08quitting at 4 weeks, wards compared with Gateshead average 2007/08quitting at 4 weeks, wards compared with Gateshead average 2007/08quitting at 4 weeks, wards compared with Gateshead average 2007/08quitting at 4 weeks, wards compared with Gateshead average 2007/08quitting at 4 weeks, wards compared with Gateshead average 2007/08quitting at 4 weeks, wards compared with Gateshead average 2007/08quitting at 4 weeks, wards compared with Gateshead average 2007/08quitting at 4 weeks, wards compared with Gateshead average 2007/08

Significantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceLower (31% to <40%)Lower (31% to <40%)Lower (31% to <40%)Lower (31% to <40%)Lower (31% to <40%)Lower (31% to <40%)Lower (31% to <40%)Lower (31% to <40%)Lower (31% to <40%)Higher (40% to <54%)Higher (40% to <54%)Higher (40% to <54%)Higher (40% to <54%)Higher (40% to <54%)Higher (40% to <54%)Higher (40% to <54%)Higher (40% to <54%)Higher (40% to <54%)Significantly higher (68%)Significantly higher (68%)Significantly higher (68%)Significantly higher (68%)Significantly higher (68%)Significantly higher (68%)Significantly higher (68%)Significantly higher (68%)Significantly higher (68%)

Where do these people live

NHS Stop Smoking Services - % of service users lost to follow-up with 95% confidence limits

0

10

20

30

40

50

60

Gateshead SouthTyneside

Sunderland South of Tyneand Wear

England

% lo

st to

follo

w-u

p


Equal chance of success?

Proportion setting a quit date, lost to follow-up

Lost to follow-up• All 39%, males 37%, females 40%• Fewer older adults lost to follow-up• Among BME groups – don’t know• Doesn’t vary with social/economic group• Lower (31%) among pregnant women• Ryton, Crookhill & Stella 49%, Dunston

Hill & Whickham East 48%

% lost to follow

up by ward in

2007/08

South

Central

Inner West



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Proportion of NHS Stop Smoking Service users lost toProportion of NHS Stop Smoking Service users lost toProportion of NHS Stop Smoking Service users lost toProportion of NHS Stop Smoking Service users lost toProportion of NHS Stop Smoking Service users lost toProportion of NHS Stop Smoking Service users lost toProportion of NHS Stop Smoking Service users lost toProportion of NHS Stop Smoking Service users lost toProportion of NHS Stop Smoking Service users lost tofollow up, wards compared with Gateshead average 2007/08follow up, wards compared with Gateshead average 2007/08follow up, wards compared with Gateshead average 2007/08follow up, wards compared with Gateshead average 2007/08follow up, wards compared with Gateshead average 2007/08follow up, wards compared with Gateshead average 2007/08follow up, wards compared with Gateshead average 2007/08follow up, wards compared with Gateshead average 2007/08follow up, wards compared with Gateshead average 2007/08

Significantly higher at 95% confidence (46% to <49%)Significantly higher at 95% confidence (46% to <49%)Significantly higher at 95% confidence (46% to <49%)Significantly higher at 95% confidence (46% to <49%)Significantly higher at 95% confidence (46% to <49%)Significantly higher at 95% confidence (46% to <49%)Significantly higher at 95% confidence (46% to <49%)Significantly higher at 95% confidence (46% to <49%)Significantly higher at 95% confidence (46% to <49%)Higher (35% to <46%)Higher (35% to <46%)Higher (35% to <46%)Higher (35% to <46%)Higher (35% to <46%)Higher (35% to <46%)Higher (35% to <46%)Higher (35% to <46%)Higher (35% to <46%)Lower (23% to <35%)Lower (23% to <35%)Lower (23% to <35%)Lower (23% to <35%)Lower (23% to <35%)Lower (23% to <35%)Lower (23% to <35%)Lower (23% to <35%)Lower (23% to <35%)Significantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidenceSignificantly lower at 95% confidence

Conclusions• Access by social/economic groups is

fair • BUT access rates below South

Tyneside and Sunderland • Low quit rate, high % lost to follow-up • Access, males, especially young males

under-represented• BME groups don’t access service

Conclusions• Some social (Mosaic®) groups under-

represented – why – focus groups?, use profiles and map of location by type?

• Some areas have lower access rates – map service provision in these areas

• 25% of pregnant smokers access service

Conclusions

• Young people aren’t successful at quitting – more support? different approach? OR raise quit rate for all ages equally?

• North West Gateshead - high proportion lost to follow-up

What next?

The four A’s

• Awareness

• Accessibility

• Availability

• Acceptability

Think about contacts at all stages in a pathway of care e.g. smoking

during pregnancy

high smoking prevalence and low uptake of services

among Mosaic Groups F & G

Women of childbearing age

6,700 women booking at 10-12 weeks

Delivery

50% (900 women) are referred to stop smoking service

28% of these (250 women) have a successful quit (at 4

weeks)

Conception

24%

27%

27%

Current state

1800 smoking

27%

Smoking during pregnancy

27%

27%

21%

24%



Delivery

Conception

26%

24%

19%

21%



Delivery

Conception

Smoking during pregnancy

What next?• Social marketing• Focus group of people in Types 22 and 24?

Why don’t they use the service?• Focus group of people in Group F? Why do

they find it difficult to quit?• Look at service pathways – who is/isn’t

referring in• Look at other approaches supporting Stop

Smoking Services

The Equity Audit Cycle

Source: Tackling Health Inequalities (2003) Department of Health

What next?

• Action plan

• Prioritise actions – most important first

• Against each action a milestone and a measure

Any questions?

Are NHS Stop Smoking Services being accessed fairly in Gateshead? Andy Billett, Public Health...

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