Dr Matt Kearney discusses how GPs can implement the NICE smoking cessation guidance to increase referral rates of smokers to specialist clinics and improve quit rates
When the Health Act 2006 becomes law on 1 July 2007, virtually all workplaces and many public places in England will become smoke free. Experience in Ireland and Scotland suggests that this will result in a significant increase in demand for help in giving up smoking. Two pieces of guidance have been published by NICE to support this—the first in March 2006,1 on brief interventions in primary care and other settings, and the second in April 2007, on interventions to help employees stop smoking.2 These will be followed by NICE recommendations covering a broad range of smoking cessation activities, due for release in November 2007, and guidance on preventing smoking in children and young people, scheduled for publication in June 2008.3
Impact of smoking
The evidence of the harm caused by smoking is overwhelming, and the statistics are striking. It is the single biggest cause of preventable illness and premature death in Britain.4 In the UK, 114,000 people die each year from smoking-related diseases,5 in particular, from coronary heart disease, stroke, and a range of cancers. Most smokers suffer years of chronic ill health as a result of their tobacco use, and half of all long-term smokers will die from smoking-related disease.6 Life-expectancy for the average smoker will be reduced by 10 years.7 The financial impact of smoking is also huge: costs to the NHS alone are estimated to be around £1.5 billion per year.8
Although smoking prevalence has fallen over the past 40 years, the rate of reduction appears to be tailing off. Currently around 25% of adults smoke,9 although this average hides significant social inequalities, with smoking rates being much higher among manual workers and the unemployed. The socioeconomic gradient in smoking habits accounts for over half of the difference in risk of premature death between different social groupings.10
Health benefits of giving up smokingStopping smoking does bring significant health benefits in both the short and the long term. Even patients with established chronic obstructive pulmonary disease, for example, can improve their lung function and reduce their mortality by smoking. People who stop smoking before the age of 35 years, and in the absence of other life-threatening conditions, will eventually have a life expectancy that is only slightly less than those who have never smoked.6
Effective cessation strategies
So what produces results in helping people to stop smoking? The NICE guidance provides the evidence that both brief and more intensive interventions to support smoking cessation do work.1 Brief interventions tend to be less effective but have wider reach, whereas more specialist smoking cessation clinics are accessed by fewer smokers but have higher success rates.11
Two-thirds of smokers say they would like to stop, and about one-third try to do so each year.12 Among those who try to quit, people who use nicotine replacement therapy (NRT) or bupropion have double the success rate of those who go 'cold turkey', and those patients who receive drug treatment plus support have approximately four times the success rate.5
Currently, of the 33% of smokers who attempt to quit each year, 21% enter a treatment programme, and 12% go 'cold turkey'. As a result of these attempts, 2.65% of smokers become long-term quitters, and remain abstinent at 12 months. Target figures are to increase the number of smokers who attempt to give up to 50%, with 40% of them undergoing treatment, and only 10% going 'cold turkey'.5
The evidence examined by NICE confirms that brief interventions are both effective in practical terms and represent value for money—they increase the number of patients entering treatment and the number who quit successfully. The model predicts that if by increasing the number of brief interventions and referrals we could persuade 50% of smokers to attempt to quit, with 40% opting for treatment and only 10% going 'cold turkey', the number of 12-month quitters would rise to 4.3%. Nationally this would produce 165,000 extra quitters per year.13
So the key to increasing the number of those successful in giving up smoking is to use more brief interventions and attract more people into treatment. The NICE guidance on brief interventions (see Figure 1, below) is explicit about the roles of GPs and other primary care professionals. It recommends that all smokers should be advised during consultations about stopping smoking unless there are exceptional circumstances, and that if they are not ready to quit they should be encouraged to seek help in the future.1
Figure 1: Brief intervention for smokers
1 Occasionally it might be inappropriate to advise a patient to quit, for example, because of their presenting condition or personal circumstances.
2 Please note: NHS Stop Smoking Services also provide pharmacotherapy.
National Institute for Health and Care Excellence (NICE) (2006) Brief interventions for smokers, from Brief interventions and referral for smoking cessation in primary care and other settings. Reproduced with permission.
Patients who want to try to stop smoking should be referred to a smoking cessation service, either in the practice or elsewhere in the community. Sometimes people ask for immediate treatment, either because they have already given up, or because they are unable or unwilling to attend a clinic. The NICE guidance advises that these patients should be given appropriate pharmacotherapy but that this must be supplemented by follow-up for support.14
It is likely, however, that in most cases treatment will be started at a smoking cessation clinic after the brief intervention by their GP, nurse, or other professional. In the author's practice in Runcorn, the clinic is run by a trained healthcare assistant (HCA). Patients can self-refer or be referred by any staff member. The HCA conducts an initial 30 minute consultation to assess motivation, history of previous quit attempts, level of dependence, and sources of support. Treatment choice is agreed with the patient and GP, taking into account individual preference, previous experience, and contraindications.
Currently, most patients attending the Runcorn clinic are prescribed NRT or bupropion—the NICE recommendations on effectiveness, including cost-effectiveness, of varenicline are scheduled for publication in July 2007. A quit date is then set and the patient is followed up every 1–2 weeks for 3 months. At each follow-up appointment, the HCA reviews progress with the patient, using a smokalyser as a motivational tool. This device is similar to a breathalyser, and measures carbon monoxide levels in the body. The HCA offers access to support materials and reduces the dose of NRT when appropriate. In line with other treatment services, around half of the patients complete the 12-week course.
A major advantage of this in-house approach is its accessibility for patients and clinicians. Practices may be able to obtain PCT funding through local enhanced service payments.
Community-based servicesAs an alternative to receiving treatment at the GP's clinic, patients can be referred into a community-based service. In Knowsley, 'Fag Ends', operated by the Roy Castle Foundation, runs clinics across the borough in a range of non-health-related settings such as community centres, church halls, and schools. Referrals are made by GPs, pharmacists, other health professionals, and community workers. Smokers receive vouchers for NRT, which they take directly to a pharmacy, and they are followed up with support for 12 weeks. Early results suggest this community model is proving much more effective than the traditional service it replaced, with a substantial increase both in numbers accessing the service and in 4-week quit rates.
With the workplace ban imminent, smoking cessation is now very much on the public agenda. The NICE evidence-based guidance gives clinicians confidence that both brief and intensive interventions are effective at attracting smokers into treatment and at increasing quit rates. The current quality and outcomes framework (QOF)15 incentivises GPs to record patients' smoking status and for referral to smoking cessation services. At present, this applies only to patients with long-term conditions, such as cardiovascular disease, but in the 2008 QOF, this is likely to be extended to the population as a whole.
- Smoking cessation services are cost effective
- There is no tariff price applicable to these services
- Investments in community and primary care services are likely to prevent morbidity and save costs in the long term
- Investment costs in pharmacotherapy are immediate — gains against budget appear later
- PBC commissioners should ensure effective and accessible smoking cessation services
- References National Institute for Health and Care Excellence. Brief interventions and referral for smoking cessation in primary care and other settings. NICE Public Health Intervention Guidance No. 1. London: NICE, 2006.
- National Institute for Health and Care Excellence. Workplace health promotion: how to help employees to stop smoking. NICE Public Health Intervention Guidance No. 5. London: NICE, 2007.
- Department of Health. Smoking Kills. London: The Stationery Office, 1998.
- West R. Smoking prevalence, mortality and cessation in Great Britain. 2005.www.rjwest.co.uk/. Accessed 12 June 2007; last updated 9 October 2005.
- Doll R, Peto R, Wheatley K et al. Mortality in relation to smoking: 40 years' observations on male British doctors. Br Med J 1994; 309 (6959): 901–911.
- Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male British doctors. Br Med J 2004; 328 (7455): 1519.
- Parrott S, Godfrey C, Raw M et al. Guidance for commissioners on the cost effectiveness of smoking cessation interventions. Health Educational Authority. Thorax 1998; 53 (Suppl 5 Pt 2): S1–38.
- Department of Health. Fact sheet on tobacco. London: DH, 2006.
- Jarvis M, Wardle J. Social patterning of individual health behaviours: the case of cigarette smoking. In Marmot M, Wilkinson R, eds. Social Determinants of Health. Oxford: Oxford University Press, 1999.
- West R, Mc Neill A, Raw M. Smoking cessation guidelines for health professionals: an update. Health Education Authority. Thorax 2000; 55 (12): 987–999.
- Royal College of Physicians. A report of the Tobacco Advisory Group of the Royal College of Physicians. Nicotine Addiction in Britain. London RCP, 2000.
- National Institute for Health and Care Excellence. An assessment of brief interventions and referral for smoking cessation in primary care and other settings with particular reference to pregnant smokers and disadvantaged groups with consideration of the tailoring and targeting of interventions—synopsis. London: NICE, 2006.
- National Institute for Health and Care Excellence. Smoking cessation—bupropion and nicotine replacement therapy. NICE Techonology Appraisal Guidance No. 39. London: NICE, 2002.
- British Medical Association. Revisions to the GMS contract 2006Ð2007: Delivering investment in general practice. London: BMA, 2006.G