A comprehensive evaluation of the impact of English tobacco control policy on smoking cessation activities

Lead Research Organisation: University of Nottingham
Department Name: School of Life Sciences

Abstract

We aim to assess the impact of recent tobacco control policies on the number of smokers who succeed in stopping smoking in England. Smoking is the single greatest cause of preventable illness and premature death in the UK, and increasing the numbers of smokers who succeed in stopping smoking is the most important way of reducing morbidity and premature death in this country.
This is the fundamental aim of many recent national tobacco policies. For example, larger and harder hitting health warnings have been introduced on cigarette packs. Financial incentives now encourage family doctors to help smokers who want to quit. Medications that aid smokers to quit, such as nicotine replacement products (NRT) have been made more accessible, for example, NRT can now be prescribed to adolescents and people with heart disease, and taxation has been reduced on over the counter sales of these treatments. Finally, a new treatment to help smokers quit has been launched, varenicline. How effective these policies and initiatives have been in increasing smokers’ attempts and success at quitting, and ultimately at improving health, has not been evaluated in any comprehensive way.
We will use several existing sources of data, including specialised and national surveys, electronic primary care patient records, sales and prescriptions for NRT, and hospital admission data, that all provide different measures of smoking behaviour in England to find out how effective each of these specific policies have been.
This work will help in establishing which policies are successful and effective and should be maintained, and which are ineffective and should be dropped.

Technical Summary

Increasing smoking cessation is probably the single most important means of reducing the burden of lung cancer, heart disease and stroke in the UK in the next 20 years. In the last decade, in England, a wide range of policies aimed at both motivating smokers to make attempts to quit and at increasing the success within these have been introduced to try to achieve this. Since 2002, approaches have included introducing larger health warnings on cigarette packs, broadening the indications on NRTs, the launch of varenicline, reducing taxation on OTC NRTs and a new, and subsequently revised, GP contract to encourage GPs to identify, advise and refer smokers to NHS Stop Smoking Services. None of the above policies have been comprehensively evaluated to determine their effects on a full spectrum of relevant outcomes and their relative impact for different populations, such as the more socio-economically disadvantaged. We therefore propose to combine existing sources of data to comprehensively evaluate the success of tobacco policies listed above. The datasets that we propose to use are: Smokers Toolkit, a series of panel surveys of smokers; The Health Improvement Network (THIN), a large Primary Care dataset; data on all dispensed prescriptions and NRT OTC sales; the Omnibus and General Household Surveys, and Hospital Episode Statistics. These datasets encompass smoker?s potential responses, like their smoking behaviour and attitudes, population-based data with information on relevant demographic and social contextual variables to determine differential impacts in different population groups, and data that captures other relevant outcomes, such as smoking-related disease and broader influences on smoking in the population. We will use these datasets to derive monthly, quarterly and annual indices of smoking cessation activity, overall and in specific groups defined by race/ethnicity, age, gender, social class and regional factors. We will assess their external validity and sensitivity to change, and will link these comprehensive aggregate measures into a single database, updating this regularly as new data becomes available. We will use these data to estimate the impact of individual tobacco control initiatives upon these outcomes using time series analysis in Stata. We will assess the feasibility of a sustainable and accessible database resource linking aggregate measures of smoking cessation activity in the English population, creating the framework and data for evaluating future policy and doing this more cost effectively than previous efforts.
 
Description consultation on the GLF
Geographic Reach National 
Policy Influence Type Participation in a national consultation
 
Description training on evaluation of policy to tobacco researchers and policy makers
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
 
Description Cancer Research UK Tobacco Advisory Group (TAG) Project Grant
Amount £15,000 (GBP)
Organisation Cancer Research UK 
Sector Charity/Non Profit
Country United Kingdom
Start 03/2011 
End 08/2011
 
Description PhD studentship awarded to study RA
Amount £20,000 (GBP)
Organisation University of Nottingham 
Sector Academic/University
Country United Kingdom
Start 10/2009 
End 09/2011
 
Description SRNT-Europe 2011 travel award
Amount £800 (GBP)
Organisation Society for Research on Nicotine and Tobacco (SRNT) Europe 
Sector Academic/University
Country Mexico
Start 09/2011 
End 10/2011
 
Title Nottingham Tobacco Control Database 
Description A database providing smoking prevalence estimates and indices of smoking cessation activity over time has been developed. It includes data from a range of data sources (THIN, General Household Survey, Omnibus Survey, Smoking Toolkit Survey, Health Survey for England, over-the-counter sales and dispensed prescriptions for smoking cessation medication). Variables in the database include estimates of smoking prevalence, the number of items of smoking cessation medications that have been prescribed, dispensed, and purchased over the counter and the proportion of general practice patients receiving advice or referrals related to smoking cessation. The data have (where possible) been divided into monthly time periods, and (where possible) divided into population-specific strata (age, sex, region and socioeconomic status). For quantities related to smoking cessation medications the data have been subdivided according to type of medication (e.g. Nicotine Replacement Therapy (NRT), varenicline or bupropion) and means of medication (e.g. tablet, gum, patch etc.). 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact The database facilitates the comprehensive evaluation of tobacco control policy in England, by combining a range of markers of smoking cessation behaviour from several datasets. Members of the project team who are also members of the UKCTAS, have been consulted by the Department of Health about the use of these datasets to measure tobacco control policies, particularly with respect to assessing effects across sociodemographic groups. The database has enabled straightforward extension of our analysis to explore impacts of other tobacco policies including mass media tobacco control advertising and cigarette pricing. 
URL http://www.ukctas.ac.uk/ukctas/what-we-do/featuredprojects/ntcd/ntcd.aspx
 
Title econometric time series methods applied in public health 
Description we have applied and described econometric time series models in a relatively novel context, as they have been little used in public health. 
Type Of Material Data analysis technique 
Provided To Others? No  
Impact time series models provide a stronger evidence base for the effect of associations with time related exposures than the more usual pre and post evaluations, and have enabled appropriate modelling of confounders, and non-linear associations. 
 
Description Collaboration between University of Nottingham and ASH 
Organisation Action on Smoking and Health (ASH)
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution We used our Nottingham Tobacco Control Database to carry out the preliminary descriptive analysis of mass media campaigns (measured in terms of Television Rating Points) and markers of smoking cessation activity. We have also provided help with interpretation of statistical and economic tobacco control research findings to support ASH in the targetting of its campaigns.
Collaborator Contribution ASH are a campaigning public health charity working to reduce the harm caused by smoking. ASH has provided initial funding to extract some of the tobacco campaign data and to enable us to use our Nottingham Tobacco Control Database (developed as part of our NPRI funded work) to do some preliminary descriptive analysis of the association between anti-smoking mass media campaigns and smoking cessation activity. ASH presented some of this preliminary work in the All Party Parliamentary Group on Smoking and Health "inquiry into the effectiveness and cost-effectiveness of tobacco control" paper submitted to the Spending Review in 2010 as evidence for the likely effectiveness of mass media campaigns, thus using our work to attempt to drive national tobacco control policy and spend.
Impact Some of the preliminary work on the effectivness of anti-smoking mass media campaigns was included in the All Party Parliamentary Group on Smoking and Health "Inquiry into the effectiveness and cost-effectiveness of tobacco control" paper submitted to the Spending Review 2010. http://www.ash.org.uk/files/documents/ASH_743.pdf. ASH was a collaborator on two subsequent applications for funding to extend this work; a successful application to CRUK and a further application for NPRI funding. This is a multi-disciplinary collaboration involving academic researchers in tobacco control and epidemiology and a campaigning public health charity.
Start Year 2010
 
Description Collaboration between University of Nottingham and UCL 
Organisation University College London
Department UCL Cancer Institute
Country United Kingdom 
Sector Academic/University 
PI Contribution Data from the Smoking Toolkit has been included in the Nottingham Tobacco Control database, and we are collaborating in work arising from the Smoking Toolkit. We have contributed to debate with RW on the relative strengths and weakness of the various datasets available for monitoring smoking behaviour and the most appropriate methods for analysis. We collaborated with RW in our preliminary work on the impact of anti-smoking mass media campaigns, and are continuing to use toolkit data to explore impacts of mass media campaigns on quit attempts.
Collaborator Contribution Access to, and on-going consultation on, the Smoking Toolkit, a monthly series of panel studies of smokers in England (from Professor Robert West, UCL).
Impact The Smoking Toolkit has more detailed information on individuals' smoking behaviour and reasons for their behaviour than is available from other data sources, and is therefore a valuable tool in our evaluation of tobacco policy and included in our developed Nottingham Tobacco Control database. This collaboration is multi-disciplinary involving expertise in statistics, epidemiology and health policy in Nottingham and health behaviour at UCL.
Start Year 2008
 
Description newspaper article 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Supported by the University of Nottingham publicity office, a media release describing the study, funding, aims and objectives, was issued, and reported in the local press.

interest from the local media
Year(s) Of Engagement Activity 2008
 
Description webpage 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact We initially created a webpage describing the study aims and objectives and linked to the UK Centre for Tobacco Control Studies website. We have subsequently developed this website to provide access to graphs showing trends in key indicators of smoking cessation behaviour, as a resource for both academic and non-academic audiences. This will enable policy makers and others to see the effects of current changes in spend on tobacco control.

This site contributed to the available data for policy makers and public alike on changes in smoking behaviour over time and in response to policy.
Year(s) Of Engagement Activity 2009,2010,2011
URL http://www.ukctas.ac.uk/ukctas/what-we-do/featuredprojects/ntcd/ntcd.aspx