How PCTs have let smokers down

Efforts to cut tobacco-related illness and death are being undermined by restrictions on drugs to help patients quit and by poor knowledge of local prevalence, experts believe.

Restriction: some PCTs insist that patients start with NRT (Photograph: Istock)
Restriction: some PCTs insist that patients start with NRT (Photograph: Istock)

A GP investigation has found that 14 per cent of PCTs restrict GPs from choosing between any of the three NICE-approved cessation drugs - NRT, varenicline and bupropion - as equal first-line treatments.

NICE advises that none of these drugs should be favoured over another, and that clinicians and patients must be allowed to choose the one that seems most likely to succeed.

But some PCTs are requiring patients to relapse while on NRT before they are allowed other drugs - even if they have already failed in the past using NRT.

Smoking cessation expert and GP Professor Paul Aveyard of the UK Centre for Tobacco Control Studies at Birmingham University says this policy makes no medical sense.

'Most people who try to quit try more than once. Most who go to clinic have used medication and most have failed on NRT,' he says. 'It is not logical to give the same treatment again.'

Cost cutting
Cost may be the motivating factor behind this policy. In 2009/10, varenicline cost the NHS £34.09 per prescription item on average, compared with NRT at £20.15. Yet varenicline was more effective than NRT: 60 per cent of patients successfully quit on varenicline only, compared with 47 per cent of those on NRT only.

NHS Bedfordshire and NHS Luton disagree with NICE's verdict. Joint policy documents sent to GP state: 'Varenicline is not recommended as a first-line treatment as currently there are no published trials comparing the drug with NRT.'

West Midlands GP Dr Charles Broomhead, a member of the Smoking Cessation in Primary Care (SCAPE) group, says PCTs are 'completely wrong to second-guess NICE'.

The institute is a 'credible organisation', he says, with expertise in examining evidence to which PCTs should adhere. He says restricting access to drugs as first-line treatments may damage patient attempts to quit.

Paucity of data
The GP investigation also highlights a paucity of PCT data on tobacco use. Just five of 120 PCTs that responded to a request for information said they held up-to-date information on all forms of tobacco use locally, a measure also required by NICE.

Potentially harmful use of smokeless tobacco is common among ethnic minority communities in England. Half of all Bangladeshi women in the London borough of Tower Hamlets chew tobacco, a highly addictive habit linked to oral cancer and cardiovascular disease. Although this form of use is limited to specific areas, data are rarely collected.

Last week, a report from the Race Equality Foundation found that tobacco use has fallen in the general population but not in ethnic minority groups. Access to smoking-cessation services remains poor among these communities.

The report advised that PCTs and local authorities with large ethnic minority communities should map local use of all forms of tobacco use when planning stop-smoking services. The GP investigation found little evidence of this occurring.

A NICE spokeswoman says: 'The guidance means that PCTs should include all these forms of tobacco in their prevalence data.

'Stop-smoking professionals understand this. PCTs should hold this data so that they can tailor their services.'

The charity Action on Smoking and Health (ASH) says use of smokeless tobacco is so common in some areas that it makes an ideal target for action. Martin Dockrell, director of research and policy at ASH, says: 'It is not rocket science. If these PCTs know anything at all about their populations then it should be very easy to identify communities where smokeless tobacco use is widespread.'

Dr Aveyard believes more PCTs in high-prevalence areas should commission local enhanced services that require GPs to record smokeless tobacco use among patients. This will give commissioners a more accurate picture of tobacco use, he says, and may improve access among ethnic minority groups.

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