Louise Ross summarises the latest recommendations from NICE on stop smoking interventions and services and highlights the relevant points for primary care

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Louise Ross

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Read this article to learn more about:

  • offering very brief advice and referring patients to a stop smoking service
  • evidence-based smoking cessation interventions
  • recommendations from NICE about the role of e-cigarettes in helping patients to quit smoking.

Key points

Implementation actions for STPs and ICSs

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Smoking remains the principal cause of preventable illness and early death in England. In 2015/16, around 474,000 hospital admissions in England were attributable to smoking-related conditions, and an estimated 16% (79,000) of all deaths in 2016 were linked to smoking.1 Smoking affects the most disadvantaged in our society, having a marked impact on health inequalities. It is worth noting that people who smoke are more likely than the general population to have additional mental health problems and co-morbidities such as cardiovascular disease, respiratory illness, and cancer.2

Stop smoking services were first set up in 1999; in the first 10 years of operation they helped nearly two million smokers to quit3 and experienced substantial footfall until about 2011.4 Since 2013, numbers attending the services have been falling sharply.1 Several possible reasons have been put forward to explain this decrease: the move of commissioning stop smoking services from NHS to local authorities, the fall in spending on national stop smoking campaigns, and the rise in popularity of e-cigarettes.

NICE guidance

In March 2018, NICE published NICE Guideline (NG) 92 on Stop smoking interventions and services.5 The new guideline updates and replaces Public Health Guideline (PH) 1 on Smoking: brief interventions and services and PH10 on Stop smoking services, and includes recommendations from other guidelines relevant to smoking. One important purpose of NG92 is to clarify the role of primary care healthcare professionals, among others, in carrying out brief opportunistic interventions and referring patients to a local stop smoking service, and how the stop smoking services should maximise the potential to turn a referral, or self-referral, into a successful quit.

Some primary care healthcare professionals, and others in different fields, have lost heart with asking their patients about smoking. Faced with repeated ‘failures’ or obdurate refusal from patients to consider stopping smoking, many clinicians struggle to continuously reinforce the stop smoking message.

The new guidance provides a fresh call to action, for two reasons.

Firstly, NG92 emphasises that everyone should be asked if they smoke (in a way that is sensitive to their preferences and needs) and advised to stop if they do.5 Training for primary care clinicians on how to deliver very brief advice on smoking (VBA) is available from the National Centre for Smoking Cessation and Training (NCSCT) website.6 Very brief advice is a successful way of engaging a patient who smokes, and it makes good use of available resources. Instead of wasting precious consultation time getting into a debate about why the patient doesn’t want to stop smoking, why they failed last time, or about their uncle who smoked 50 cigarettes a day and still lived till he was 90 years old, the VBA approach—ask, advise, act—gets straight to the heart of the matter. If this is successful in triggering an attempt to quit, it is best supported by a stop smoking service. Primary care clinicians need to know how to make a referral to their local stop smoking service, as pathways vary in each locality.5

Secondly, NG92 addresses the issue of e-cigarettes. It is hard to deny the effectiveness of e-cigarettes as aids for stopping, or reducing the harm of, smoking. Martin Dockrell, Tobacco Control Programme Lead for Public Health England, has written two informative blogs explaining the popularity and effectiveness of e-cigarettes7,8 and the NCSCT has produced several useful resources, including a briefing and an e-learning course. See Box 1 for further information.

Box 1: Resources for healthcare professionals about stopping smoking

Very brief advice on smoking—online training6 (NCSCT)

This short online training module for healthcare professionals focuses on how to deliver very brief advice on smoking.

Clearing up some myths around e-cigarettes7 (PHE)

This blog, written by Martin Dockrell, Tobacco Control Programme Lead for Public Health England, explores the most common myths about e-cigarettes.

Seizing the opportunity: e-cigarettes and stop smoking services—linking the most popular with the most effective8 (PHE)

This blog, written by Martin Dockrell, Tobacco Control Programme Lead for Public Health England, considers how stop smoking services can support people who wish to use e-cigarettes in their attempt to quit smoking.

Electronic cigarettes: a briefing for stop smoking services9 (NCSCT)

This briefing makes recommendations for stop smoking practitioners and services, and provides common questions and suggestions.

E-cigarettes: a guide for healthcare professionals10 (NCSCT)

This online training course was developed to assist health and social care professionals in supporting people who want to use electronic cigarettes (e-cigarettes) to help them quit smoking.

Briefing on electronic cigarettes11 (ASH)

This ASH briefing paper provides information about electronic cigarettes, the reduced harm compared to cigarettes and how they can help people quit smoking.

The smokefree formula12 (Professor Robert West)

This book, intended for use by smokers and healthcare professionals, describes how people can create their own guide for stopping smoking, and provides information and non-judgmental advice about the different approaches to quitting. 

E-cigarettes in pregnancy13 (Smoking in Pregnancy Challenge Group)

An infographic with some important guidance about using e-cigarettes in pregnancy.

Smoking in Pregnancy Challenge Group14

The Smoking in Pregnancy Challenge Group is a coalition of public health, maternity, and baby organisations working to support the Government’s goal of reducing rates of smoking in pregnancy. It has produced a number of publications related to smoking in pregnancy.

NCSCT=National Centre for Smoking Cessation and Training; PHE=Public Heatlh England; ASH=Action on Smoking and Health

Smoking cessation aids

There are a range of aids for stopping smoking available to people who try to quit. Some methods (e.g. the Allen Carr method,15 hypnotherapy, cold turkey, prayer) may be effective, but they do not have the strength of evidence of recommended interventions. Evidence-based methods include:5

  • behavioural support (individual and group) from a trained stop smoking professional
  • tailored text messaging as an adjunct to behavioural support
  • long- and short-acting nicotine replacement therapy (NRT), preferably in combination
  • varenicline tartrate (should normally be prescribed as part of a programme of behavioural support in line with NICE Technology Appraisal 123)5,16,17
  • bupropion.18

E-cigarettes

NICE has acknowledged the increased use of e-cigarettes as a tool for stopping smoking, and has included recommendations on their use (see Box 2).5 Many people have found e-cigarettes helpful to quit smoking regular cigarettes and they should also be included in the list of stop smoking aids.5 Compared with the licensed medications discussed above there has been less research around the use of e-cigarettes, but the current available evidence suggests that they are substantially less harmful than smoking.19 Results from a randomised controlled trial comparing e-cigarettes with nicotine replacement therapy, led by Professor Peter Hajek at Queen Mary University of London, are due to be published soon.

Box 2: NICE Guideline 92 recommendations on e-cigarettes5

For people who smoke and who are using, or are interested in using, a nicotine-containing e-cigarette on general sale to quit smoking, explain that:

  • although these products are not licensed medicines, they are regulated by the Tobacco and Related Products Regulations 2016
  • many people have found them helpful to quit smoking cigarettes
  • people using e-cigarettes should stop smoking tobacco completely, because any smoking is harmful
  • the evidence* suggests that e-cigarettes are substantially less harmful to health than smoking but are not risk free
  • the evidence in this area is still developing, including evidence on the long-term health impact.

* See reports by Public Health England (E-cigarettes and heated tobacco products: evidence review), the British Medical Association (E-cigarettes: balancing risks and opportunities) and the Royal College of Physicians (Nicotine without smoke: tobacco harm reduction).

© NICE 2018 Stop smoking interventions and services. Available from www.nice.org.uk/guidance/ng92 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Developing local evidence-based strategies

During the development of NG92 it was acknowledged that since the commissioning of stop smoking services transferred from the NHS to local authorities, local variation had increased, and in some areas, the stop smoking support that had previously been taken for granted is no longer available in the same measure. However, a benefit of local authority involvement is that the local joint strategic needs assessments, sustainability and transformation plans, and tobacco control profiles can be used to add weight to the need to tackle smoking.5

Special considerations

There are specific groups who not only smoke more heavily than the general population, but who are also more resistant to the stop smoking message. Groups who are more at risk from smoking-related illness should be prioritised in any local plans to tackle smoking rates, in a way that is non-judgmental, sensitive to the needs of individuals, and demonstrates an understanding of the life issues these groups face. Specific groups who may be at high risk of tobacco-related harm include:5

  • people with mental health problems, including mental health disorders
  • people who misuse substances
  • people with health conditions caused or made worse by smoking
  • people with a smoking-related illness
  • populations with a high prevalence of smoking-related morbidity or a particularly high susceptibility to harm
  • communities or groups with particularly high smoking prevalence (such as manual workers, travellers, and lesbian, gay, bisexual, and trans people)
  • people in custodial settings
  • people living in disadvantaged circumstances
  • pregnant women who smoke.

Education and training for primary care workers

The NCSCT, Action on Smoking and Health (ASH), and Public Health England (PHE) have produced a range of training materials, resources, and factsheets on stopping smoking (see Box 1).

Healthcare professionals who want to gain a deeper understanding of the practical ways in which stop smoking practitioners assist smokers to become smokefree could approach their local service and ask to shadow a clinic; most services would be happy to set up a session to observe.

Stopping smoking before surgery

NICE Guideline 92 highlights the need to support patients listed for elective surgery to stop smoking—an opportunity that is frequently missed.5 Very brief advice using the NCSCT method could make a big difference to patients’ outcomes following surgery, including the amount of anaesthetic needed, recovery time, and length of hospital stay.20

Smoking in the workplace

NICE also makes recommendations about negotiating a smokefree workplace, with a more emphatic call to action for employers.5 This might be an excellent opportunity to review the smoking policies of your workplace, and to encourage your workforce to consider going completely smokefree. This should include not treating e-cigarettes like smoked cigarettes and being prepared to congratulate staff who switch from smoking to vaping as they are taking positive steps to improve their health.21

Implementation challenges

NICE Guideline 92 recommends that healthcare workers discuss the behavioural and pharmacotherapy options as part of a stop smoking intervention, taking into consideration previous use of stop smoking aids and adverse effects, and contraindications associated with the different pharmacotherapies.5 During a 10-minute consultation there may not be time for this level of detail, and unless clinicians have undertaken training and/or shadowed a stop smoking practitioner, they may not have the knowledge, skills, or experience to ‘add value’ to a quit attempt. In such cases, it would be preferable to refer the patient straight to the stop smoking service, where an experienced practitioner will be able to tailor an evidence-based package to suit the individual. The role of the referring clinician is to reinforce the benefits of quitting, convince the patient that they will be supported throughout their quit attempt, and that they will not regret their decision to stop smoking.

Sources of further information

Smokers, their families, and practitioners alike often want to know more about e-cigarettes and vaping. The resources produced by leading tobacco control organisations give information that may be useful from an evidence perspective, but it should be acknowledged that vaping is technically more difficult than popping a cigarette into the mouth and lighting it. To successfully switch from cigarettes to e-cigarettes requires learning and confidence (what to buy, where from, how to use it, what to do when glitches occur). There are no books about these nuances because it is such a fast-developing field—materials fast become out of date as better products become available and more sophisticated expertise develops. Anyone wanting to extend their knowledge should explore internet forums, blogs, and YouTube (a particularly useful film is The Switch, produced by the NCSCT22), and equally important, talk to experienced vapers to get their views.

Conclusion

NICE Guideline 92 on Stop smoking interventions and services provides a timely refresher about well-recognised treatment methods, but with a very welcome focus on new ways to encourage and support smokers to see the positives of a smokefree life. If primary care practitioners can embrace these new concepts, smoking rates could fall faster than ever.

Louise Ross

Member of the guideline development group for NG92

Retired Stop Smoking Service Manager, Leicester

Key points

  • Smoking remains the single most significant cause of preventable early mortality and disease
  • Implementation of NICE Guideline 92 could help accelerate the fall in smoking rates
  • There are priority groups who smoke most heavily and need special attention if they are to be persuaded to quit
  • Clinicians can learn to be more effective when offering brief advice, without any detriment to appointment length
  • E-cigarettes are popular with people who used to smoke and effective at helping them to stop smoking
  • Learning about vaping is unlikely to come from written material; online sources of information should also be explored
  • Licensed medications are also effective as stop smoking aids, especially when combined with behavioural support from a trained stop smoking advisor
  • The transfer of responsibility for tackling smoking to local authorities brings new opportunities for effective commissioning
  • There are free learning opportunities for primary care practitioners, via the National Centre for Smoking Cessation and Training
  • GP surgeries are also workplaces and should have robust policies to encourage all staff to go smokefree.

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources. 

  • Agree with local representatives from public health through health and wellbeing boards a local strategy for smoking cessation and prevention
  • Capture and define this in the local health and wellbeing plan with a view to targeting specific groups
  • Make it clear who is responsible for what but make it everybody’s business
  • Require each organisation delivering health care to offer smoking cessation advice through contracts
  • Ensure smoking cessation information and support is easily available to patients through websites, leaflets, and in healthcare premises
  • Audit smoking rates and quit rates locally and address health inequalities.

STP=sustainability and transformation partnership; ICS=integrated care system

References

  1. NHS Digital. Statistics on smoking, England: 2017. NHS Digital, 2017. Available at: digital.nhs.uk/catalogue/PUB24228
  2. Harker K, Cheeseman H. The stolen years—the mental health and smoking action report. Action on Smoking and Health (ASH), 2016. Available at: ash.org.uk/information-and-resources/reports-submissions/reports/the-stolen-years/
  3. West R, May S, West M et al. Performance of English stop smoking services in first 10 years: analysis of service monitoring data. BMJ 2013; 347: f4921.
  4. Department of Health. Towards a smokefree generation—a tobacco control plan for England. DH, 2017. Available at: www.gov.uk/government/publications/towards-a-smoke-free-generation-tobacco-control-plan-for-england
  5. NICE. Stop smoking interventions and services. NICE Guideline 92. NICE, 2018. Available at: www.nice.org.uk/ng92
  6. National Centre for Smoking Cessation and Training (NCSCT). Very brief advice on smoking. elearning.ncsct.co.uk/vba-launch (accessed 12 April 2018)
  7. Dockrell M. Clearing up some myths around e-cigarettes. PHE. Public health matters blog, 2018. Available at: publichealthmatters.blog.gov.uk/2018/02/20/clearing-up-some-myths-around-e-cigarettes/
  8. Dockrell M. Seizing the opportunity: e-cigarettes and stop smoking services—linking the most popular with the most effective. PHE. Public health matters blog, 2018. Available at: publichealthmatters.blog.gov.uk/2018/03/21/seizing-the-opportunity-e-cigarettes-and-stop-smoking-services-linking-the-most-popular-with-the-most-effective/
  9. McEwen A, McRobbie H. Electronic cigarettes: a briefing for stop smoking services. NCSCT, 2016. Available at: www.ncsct.co.uk/publication_electronic_cigarette_briefing.php
  10. National Centre for Smoking Cessation and Training. E-cigarettes: a guide for healthcare professionals. elearning.ncsct.co.uk/e_cigarettes-launch (accessed 12 April 2018).
  11. Action on Smoking and Health. Electronic cigarettes (also known as vapourisers). ASH, 2016. Available at: ash.org.uk/stopping-smoking/ash-briefing-on-electronic-cigarettes-2/
  12. West R. The smokefree formula—a revolutionary way to stop smoking now. London: Orion Books, 2014.
  13. Smoking in pregnancy challenge group. E-cigarettes in pregnancy. Available at: smokefreeaction.org.uk/wp-content/uploads/2017/06/SIPe-cig-infographic.pdf
  14. Smoking in pregnancy challenge group website. smokefreeaction.org.uk/smokefree-nhs/smoking-in-pregnancy-challenge-group/ (accessed 1 May 2018).
  15. Allen Carr’s Easyway website. Top 10 tips on how to stop smoking—Allen Carr’s easyway. www.allencarr.com/free-information/stop-smoking/top-tips-on-how-to-stop-smoking-using-allen-carrs-easyway/ (accessed 26 April 2018).
  16. NICE. Varenicline for smoking cessation. Technology Appraisal 123. NICE, 2007. Available at: www.nice.org.uk/ta123
  17. NICE website. BNF. Varenicline.bnf.nice.org.uk/drug/varenicline.html (accessed 9 May 2018).
  18. NICE website. BNF. Bupropion hydrochloride.bnf.nice.org.uk/drug/bupropion-hydrochloride.html (accessed 9 May 2018).
  19. Public Health England. Evidence review of e-cigarettes and heated tobacco products 2018. PHE, 2018. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/684963/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf
  20. Action on Smoking and Health. Joint briefing: smoking and surgery. ASH, 2016. Available at: ash.org.uk/information-and-resources/briefings/briefing-smoking-and-surgery/ (accessed 1 May 2018).
  21. Action on Smoking and Health. Will you permit or prohibit electronic cigarette use on your premises?—five questions to ask before you decide. ASH, 2015. Available at: ash.org.uk/information-and-resources/briefings/will-you-permit-or-prohibit-e-cigarette-use-on-your-premises/ (accessed 1 May 2018).
  22. NSCSTfilms. The Switch. YouTube, 2018. www.youtube.com/playlist?list=PLvBx3_9F8cFmB6Y_pWsawuQhdy-x_1i4K (accessed 1 May 2018).