Cohorts and reporting periods

This section begins by explaining the process for the original LTP commitment services (acute inpatients, mental health inpatients and maternity). Sections 2.5 and 2.6 then detail the differences for NHS specialist community mental health services and the National Digital Tobacco Treatment Service (DTTS). Submitters of NHS specialist community mental health services or national digital data should read all sections.

For each reporting period trusts are required to submit aggregate and patient level data. The amount of patient level data to submit depends on whether the patient is identified as a smoker and if they are referred to the Tobacco Dependence Service. Aggregate level data can be submitted prior to starting service delivery.

All aggregate level metrics are in-month activity. This means data that is reported in the same month as the activity occurs. For example, a patient is admitted in April and they are reported in the April dataset which is submitted a month in arrears in June.

Sites should aim to ascertain the smoking status of all patients (with those aged 16+ included in the collection) regardless of whether their smoking status has previously been recorded, for example by their GP. Ideally, this should be established at admission or booking, or as soon as practically possible. 

Sites should provide aggregate counts of patients who have been in contact with the hospital during the reporting period and have a recorded smoking status (of any category). For example, in maternity services, the aggregate return would include a count of all pregnant women who have a smoking status recorded at booking (or first contact if seen prior to a formal booking).

Counts should be specific to outpatient, inpatient, community, and maternity settings and should only be reported for settings where there is a tobacco dependence service being delivered by the trust. For example, if inpatient services are offered, but not outpatient services, then the trust would only submit aggregate inpatient data. 

The patient level activity is reported in the month the FINAL activity occurs. For example a patient admitted in January but who’s final activity on the tobacco dependence pathway occurs in May is reported in the May dataset which is submitted a month in arrears in July. Similarly, a woman with a maternity booking in December but who’s pregnancy ends in May is also reported in the May dataset (and submitted in July).

The patient level data required depends on whether the patient is identified as a smoker and if they are referred to the Tobacco Dependence Service. See the Patient not referred to a tobacco dependence treatment service and Patient referred into a tobacco dependence treatment service sections and also appendix 2 for a list of triggers for reporting.

Patient not referred to a tobacco dependence treatment service

If a patient is identified as a smoker (or a nicotine vaping product user) but is not referred for in-house support, then they are reported on discharge from hospital (or for outpatients and community appointments the date of the appointment when smoking status was recorded but a referral did not take place) and a limited (demographic and care contact details) record submitted. For maternity patients smoking status at 36 weeks and at delivery is required for all patients in this cohort.

For example, if a patient is admitted in April, and is identified as a smoker, but opts‑out of a referral to see a tobacco dependence adviser and is subsequently discharged from hospital in April, then the pathway will be deemed as complete upon discharge from hospital and the limited patient level dataset submitted as part of the April dataset during June.

For maternity patients, the end of the pathway is the end of pregnancy (refer to appendix 1 for definition).

Patient referred into a tobacco dependence treatment service

If a patient is identified as a smoker and is referred, then they are reported at the end of their pathway and a full record is required to be submitted. For example, a patient admitted in January whose 28-day outcome (end of pathway) falls in March is reported in the March dataset which is submitted a month in arrears in May.

The definition of end of pathway varies depending on the patient’s circumstances:

• for maternity patients, the end of the pathway is the end of pregnancy (refer to appendix 1 for definition).
• where a patient is seen by the tobacco dependence treatment adviser and supported to make a quit attempt, or to reduce their smoking or to achieve a temporary abstinence, they should be followed up at 28 days and the outcome ascertained and recorded. The date that the 28-day outcome is recorded is the end of the pathway for data reporting purposes, although support may continue. (See section 2.4.8 for further details on the reporting the 28-day outcome)
• where an inpatient is referred but is not supported to quit or reduce smoking, for a variety of reasons including patient choice. They are therefore not followed up at 28 days and so the end of the pathway is the date of discharge from hospital
• for those services delivered in outpatient and community settings, the patients should have a follow up 28 days after their agreed quit date. The end of the pathway, for data recording purposes, will be at the date the 28-day outcome is recorded, although support may continue. For those who do not take up an offer of support (via a supported care plan) the end of the pathway will be the date of the meeting with the tobacco dependence adviser where that decision was discussed and decided 

Patient is a non-smoker

If a patient is identified as a non-smoker and is not a nicotine vaping product user then no patient record data is required in this instance.

The exception is if any non-smokers are referred to the tobacco dependence service for clinical reasons, for example patients who have very recently quit smoking and need additional support to remain smokefree. In this case only the limited (demographic and care contact details) record is required, along with smoking status at 36 weeks and delivery for maternity patients.

Definition of a smoker

For the purposes of this data collection, smokers are defined as people who have had a cigarette regularly (at least one per week) or occasionally (less than one cigarette per week), with 2 weeks or less since their last cigarette (see “smoking status categories” in Appendix 1 for more details). This will include smokers who are also nicotine vaping product users (dual users) and individuals undertaking a current quit attempt, either supported or unsupported.

Definition of referred in-house

Full patient level data should be submitted for all patients referred to see a Tobacco Dependence Adviser within a tobacco dependence treatment service hosted by the trust (in-house), even if the episode of care is subsequently completed by a different external provider, i.e. started in the trust but completed by another provider.

If a patient (smoker) is just provided brief advice and directed/referred to an external provider, for example a local authority stop smoking service, and does not access an in‑house service, they are not considered as REFERRED IN-HOUSE and only a limited (demographic and care contact details) record should be submitted

Intervention settings

Patient level data is required for three intervention settings within which the tobacco dependence service can be delivered:

• acute (physical)
• mental health
• maternity

These are combined with the following activity types (typically the episode of care where a referral was offered) to identify where in the health service the patient originated:

• admitted patient episode – inpatient
• outpatient clinic attendance
• community care contact
• community mental health services patient contact
• admitted patient episode – community inpatient
• primary care appointment

For example :

• acute inpatients: Intervention setting type = acute (physical) and activity type = admitted patient episode
• maternity antenatal appointments: Intervention setting type = maternity and activity type = Outpatient clinic attendance
• mental health inpatients: Intervention setting type = mental health and activity type = Admitted patient episode - Inpatient
• If a patient is seen at a community appointment for a physical complaint, this would be INTERVENTION SETTING TYPE = Acute (physical) and ACTIVITY Type = Community care contact.

Patient level data is required for three intervention settings within which the tobacco dependence service is delivered

Any patients that are known to be deceased at the time of reporting should also be excluded from the aggregate section of the data submission. 

Starting a quit attempt

For (acute and mental health) inpatients starting a quit in hospital (an environment of forced abstinence), commencement of the “28-day clock” should only start upon their discharge (when the quit is voluntary). For maternity, outpatient and community settings, the 28 days would start on an agreed quit date..

People in receipt of a supported temporary intervention such as medication/NRT to support abstinence whilst in hospital can convert this into a quit attempt. These patients should be followed up for a 28-day outcome status alongside patients that have instigated a formal quit attempt.

If an inpatient has a long length of stay (beyond 28 days), their quit date is therefore their INTENDED SMOKING QUIT DATE rather than discharge date. The outcome of this quit attempt should be recorded whilst the patient is still an inpatient and the patient’s details reported when this is known (i.e. before discharge).

See the definition of 'autonomous quit' in appendix 1 for more details.

Multiple admissions/service contacts

Patients readmitted within the 28-day period from when a current supported quit attempt has started shouldn't be double-counted (i.e. shouldn’t be included multiple times in the patient level collection, although each admission should be counted in the aggregate data). If a patient is on a current supported quit attempt and is subsequently readmitted, then the “clock” will continue to count, despite the new episode of forced abstinence in hospital.

Those already on a quit attempt should be recorded using the smoking status field using the category “SMOKER UNDERTAKING A CURRENT SUPPORTED QUIT ATTEMPT”. This should only be used when ascertaining smoking status and only where someone is actively being supported (by NHS or community providers) on a current supported quit attempt (with behavioural interventions and in many cases, nicotine containing products (both licensed and unlicensed) / Varenicline/Bupropion/Cytisine³. Categorising a patient in this way acknowledges their quit and would allow them to be excluded from the count of active smokers eligible for support. This would include readmissions but potentially any other admission/maternity booking where a patient is being supported prior to contact with the NHS service. Further details are provided in appendix 1 (see “Smoker undertaking a current supported quit attempt”).

For patients on a current supported quit attempt only the limited (demographic and care contact details) record is required.

For non-maternity patients, if the patient has lapsed back to smoking between admissions/appointments, this should be recorded and reported (based on the previous care episode) as a complete pathway. A new quit attempt should be initiated (linked to the new admission/appointment) and this would precipitate a new patient level record submission.

Multiple quit attempts

If a patient on a quit attempt smokes during the first 14 days of the attempt, they can continue on their quit attempt. According to the Russell Standard to make a successful quit attempt, a patient has to not have smoked (not even a single puff) in the final two weeks of their attempt.

However, depending on the patient’s setting and situation, different reporting of multiple quit attempts is required.

1. For most patients, including inpatients, long-stay inpatients, mental health inpatients or community patients.

Each quit attempt should be recorded and reported.

Report in the dataset for the month when the outcome occurs for example if the 28‑day outcome falls in April, it is reported in the April dataset which is submitted a month in arrears in the June reporting window.

Treat multiple quit attempts as separate referral pathways - submit a whole new patient record for each quit attempt.

2. Maternity patients

If multiple quit attempts are made during a pregnancy, it is only the last attempt, and related pathway, that should be recorded in the patient level section. However, local reporting should seek to capture all relevant activity and outcomes.

Report the number of quit attempts undertaken whilst on the maternity pathway in the field: NUMBER OF QUIT ATTEMPTS.

3. Digital App users

The criteria for reporting multiple quit attempts will be set in the service specification for the NHS DTTS and reported by the nationally commissioned partner organisation.

Reporting 28-day outcome data

The 28-day outcome is an important outcome measure and needs to be reported as part of the return to ensure that impact of the tobacco dependence treatment service can be quantified. There is a requirement on the NHS provider to establish and report the outcome of the care pathway initiated in secondary care settings. In instances where the step-down care is transferred between different organisations, for example to local authority commissioned stop smoking service, it is still a requirement of the NHS submission to include the 28-day quit outcome information, and as such, local data sharing arrangements may need to be agreed to facilitate reporting.

For the purposes of reporting the 28-day outcome, so we are using the same reporting window of minus 3 to plus 14 days, so from 25 to 42 days, is the same as National Centre for Smoking Cessation and Training parameters for community services.

All patients who instigate a quit attempt or support from the tobacco dependence service to reduce the amount they smoke or achieve a period of temporary abstinence, should be followed up at 28 days.

If the smoking status is unknown at the end of the 28-day outcome reporting window, then they will be assumed to be lost to follow up. That means assumed as smokers in analysis.

Service description

Specialist tobacco dependence treatment services for people with mental health conditions, who are not inpatients at mental health trusts, will be commissioned by Integrated Commissioning Boards (ICBs). The service providers will differ between areas and may include specialist community mental health trusts, primary care networks and other providers. The overarching term for these services is specialist community mental health tobacco dependence treatment services.

This section provides additional information for those providing specialist community mental health tobacco dependence treatment services. Services delivered in inpatient settings are covered earlier in section 2. The only exception is where there is agreed step down services between care initiated in mental health inpatient settings and the NHS specialist community mental health tobacco treatment services.

There are currently two main delivery models for specialist community mental health tobacco dependence treatment services:

• specialist community mental health trusts providing services for their patients and patients discharged and referred from inpatient settings
• primary care based services providing services primarily for patients registered with participating GP practices but who may also accept referrals from other sources

Patient level data: Cohort to report

The type of activity to be collected within each ICB/provider will be agreed as part of the project initiation and should include clear guidance on which clinical settings/services are in scope for receipt of tobacco dependence treatment services and therefore need to be reported against. Please refer to the delivery model. 

Providers of NHS specialist community mental health tobacco dependence treatment services to patients referred from primary care should collect data on all these patients but only need to report on those patients who are on the Quality and Outcomes Framework (QOF) Serious Mental Illness (SMI) disease register² to this national data collection.

Referred for ongoing support

Where tobacco dependence treatment is instigated in an inpatient setting but then continued in an NHS Specialist Community Mental Health tobacco dependence (or alternative) service, the inpatient service will be responsible for submitting the patient data for the whole pathway instigated in inpatient settings (the pathway ending with the recording of the 28 day outcome status) including the part delivered by any subsequent provider. The “subsequent” service will therefore need to share patient level outcome data back to the referring service for example could complete a discharge from tobacco dependence treatment service report and send it to the initiating inpatient service to facilitate this process (with appropriate local data sharing agreements).

The contribution and type of the “subsequent” service should be recorded in the REFERRED FOR ONWARD SUPPORT field.

Where a patient is supported to 28 days and an outcome recorded post discharge but subsequently relapses back to smoking, a new supported pathway maybe initiated with the specialist community mental health service. This new treatment episode would be reported by the specialist community mental health service provider.

Definition of In-house

Unlike inpatient and maternity services where tobacco dependence treatment service providers are expected to be in the same organisation or deliver in-reach care, it is recognised for specialist community mental health tobacco dependence treatment services that there may be multiple organisations commissioned to deliver different parts of the patient pathway. As such, patients can be referred between organisations and remain “in-house” as long as they stay within organisations commissioned to deliver the pathway and ensure continuity of care is maintained within NHS funded services.

This means that all referrals to NHS specialist community mental health tobacco treatment services commissioned by the ICB are considered in-house and should be reported as such in this data collection.

Activity types

Only two of the available activity types should be used for NHS specialist community mental health patients:

• community mental health services contact
• primary care appointment

Patients identified in community mental health provision and referred to the NHS specialist community mental health tobacco dependence service should be recorded under Activity type = Community Mental Health Services contact.

Mental health inpatients discharged before being seen by the in-house service and instead signposted/referred to the NHS specialist community mental health tobacco dependence service should be recorded under the “Community Mental Health Services contact” category.

Referrals to specialist community mental health tobacco dependence services from Primary Care may be from a routine appointment or an NHS Health Check (including those for people with severe mental illness and learning disabilities).  These are all considered ACTIVITY TYPE = Primary Care Appointment. Primary care appointments do not usually have a unique identifier and therefore no activity identifier (similar to hospital spell ID) is required for this activity type.

Smoking reduction 

For patients accessing support via Specialist Community Mental Health services, NICE guidance recognises that smoking reduction may be a more prevalent strategy to engage patients. Therefore, for this cohort of patients, additional flexibility to move between smoking reduction and supported quit attempts in care plans has been introduced. This means there is the option available to start a period of smoking reduction (for 12 weeks maximum) and convert to a supported quit attempt at any point. This effectively means that the start of the 28-day outcome period could be delayed for those on a smoking reduction care plan up to a maximum of 12 weeks. In some instances, the 28-day outcome may therefore be ascertained up to 16 weeks after the care plan was agreed.

The following scenarios are therefore permissible for the Specialist Community Mental Health services pathway.

• if smoking reduction (Care Plan #20) is chosen: at any time up to 12 weeks (84 days) this can be changed into a supported quit attempt and a 28 day follow up period will commence from the agreed quit date and the outcome recorded. The original care plan should be amended to a supported quit attempt care plan, effectively overriding the original smoking reduction care plan.
• If smoking reduction (Care Plan #20) is chosen and either patients disengage during the 12-week period or no decision is made to change to a supported quit attempt within 12 weeks (84 days): the outcome (smoking status) at 12 weeks is recorded. This should be recorded in the TOBACCO CARE PLAN OUTCOME AT 28 DAYS field despite the period being 12 weeks.  In this scenario the TOBACCO DEPENDENCE CARE PLAN would remain Smoking Reduction (#20).

After this outcome is recorded, further care plans can be agreed and will need to be reported as new records (for example if a quit attempt is made after the initial Smoking Reduction care plan is outcomed or if the initial 12 week period of smoking reduction is followed by a subsequent period of smoking reduction).

• If a supported quit attempt care plan is chosen at the first meeting this cannot be changed. Irrespective of whether a smoking reduction is subsequently agreed instead, the outcome (smoking status) should be recorded 28-days after the original intended quit date was agreed and reported against the relevant supported quit attempt care plan).  A new record could then be started with a Smoking Reduction care plan if required.

This section relating to smoking reduction does not apply to those accessing services as mental health inpatients or to any service for non-mental health patients.

Aggregate data fields

For NHS specialist community mental health tobacco dependence services delivered by a specialist community mental health service provider, a count of patient contacts with community mental health services is required. As for non-mental health outpatient and community appointments only data from the first (as opposed to follow-up) appointments is required. Data is also to be submitted monthly based on the activity that occurs within that period and reported a month in arrears (activity occurring in April is reported as April activity and reported in June).

Where the specialist community mental health service is not involved in the delivery of the tobacco dependence service no aggregate fields are required to be completed because of the burden it would put on alternative (or 3^rd party) providers to obtain this information from the specialist community mental health service.

For NHS specialist community mental health tobacco dependence services drawing a patient cohort from primary care, the number of patients who are current smokers and on the GP SMI register (for eligible practices) should be reported in the field “SMOKERS IDENTIFIED IN PRIMARY CARE”. See section 3.1, data element 11 for more details. This will be an annual count over the previous 12 months and cannot be directly compared to the number of patients referred or seen in any given month.

This section refers to the national service only and will only be reported by the partner organisation contracted to deliver this service, not local providers/services/trusts.

DTTS Master DataSet (MDS)

The DTTS MDS details all of the patient level data that will recorded and reported to NHS England by the DTTS service providers and the referral management hub contracted to deliver the service.  The MDS is supported by guidance and business rules and these show the subset of the MDS data that needs to be reported to this data collection including when and how to do so.

The following sub-sections provide summary information about some of the key issues around the DTTS data but are included for information only and the DTTS documentation should be referred to for precise definitions and instructions around data reporting requirements.

Aggregate fields

None of the fields capturing aggregate counts of people with a completed smoking status are required for the DTTS.

Patient section - fields not required 

The following fields aren’t required for submissions from the DTTS:

• INTERVENTION SETTING TYPE
• ACTIVITY TYPE
• ACTIVITY DATE AND TIME
• HOSPITAL PROVIDER SPELL IDENTIFIER
• PREGNANCY IDENTIFIER
• OUTPATIENT ATTENDANCE IDENTIFIER
• COMMUNITY CARE CONTACT IDENTIFIER
• SEEN BY IN-HOUSE SERVICE FOLLOWING REFERRAL
• ATTENDANCE DATE (IN-HOUSE SERVICE FOLLOWING REFERRAL)
• Any maternity only fields

Smoking and vaping status

These fields should be completed based on smoking and vaping status at time of referral or for self-referrals this should be recorded on first contact with the digital service/app.

Referral to in-house service

All users of DTTS would automatically be counted as referred to the in-house service. For self-referrals the date of referral will be the first contact with the referral management function.