Investing a small amount of time in helping smokers to quit can produce significant benefits for patients and the practice, as Dr Kevin Lewis explains


   

The NICE guidance on brief interventions and referral for smoking cessation, published in March 2006, encourages health professionals to engage fully with the NHS stop smoking services now available to help smokers quit.1 It is the first public health guidance to be issued by NICE, reflecting both the priority attached to tackling smoking and the importance of the role played by GPs and other frontline health professionals.

The guidance does not address the provision of intensive quitting support, but instead makes recommendations on how to integrate brief smoking cessation advice into routine clinical care.

A brief intervention is described by NICE as lasting for no more than 5-10 minutes, and including one or more of the following:

  • simple opportunistic advice to stop smoking
  • an assessment of the patient's commitment to quit
  • an offer of pharmacotherapy and/or behavioural support
  • provision of self-help material and referral to more intensive support, such as the NHS stop smoking services.

Smoking is the leading cause of preventable illness, disability and premature death in the UK,1,2 and contributes to the development of a wide range of diseases, including:

  • coronary heart disease, stroke and peripheral arterial disease
  • cancer of the lung, pharynx, larynx, tongue, oesophagus, stomach, pancreas and bladder
  • chronic obstructive pulmonary disease.

About one-quarter of the adult population in the UK are smokers but the prevalence is much higher in certain groups, such as those on low incomes. The difference in smoking prevalence between those on low and high incomes accounts for more than half the difference in life expectancy between these groups.3

The main reason people continue to smoke is their addiction to nicotine. In its landmark report into nicotine addiction, the Royal College of Physicians concluded that most smokers do not smoke out of choice but because they become addicted to nicotine when they start smoking as adolescents. The RCP also stated that cigarettes are as addictive as drugs such as heroin or cocaine.4 It is not surprising that most smokers find quitting difficult, and that those who try to quit on their own are often unsuccessful.

Despite the power of nicotine addiction there is some good news. Studies show that the majority of smokers want to quit,5 and that significantly improved quit rates can be achieved with the provision of professional support and pharmacotherapy.6

In response to this, and following the publication of the Government's White Paper Smoking Kills, NHS-funded stop smoking services have been established across the UK.7 All health professionals now have the opportunity to provide smokers with the help they need to quit successfully – by raising the issue of smoking, offering brief advice, and referring to the NHS stop smoking services.

NICE recommendations

Box 1, summarises the key recommendations from the NICE public health guidance on smoking cessation, and Figure 1 illustrates the proposed care pathway.

Figure 1: Brief intervention for smokers
Reproduced by kind permission of the National Institute for Health and Care Excellence
Box 1: Key recommendations from NICE public health guidance on smoking cessation
  • GPs should take the opportunity to advise all patients who smoke to quit when they attend a consultation
  • People who smoke should be asked how interested they are in quitting
  • Those who want to stop should be offered referral to an intensive support service (for example, NHS stop smoking services). If they are unwilling or unable to accept this referral they should be offered pharmacotherapy and additional support
  • People who are not ready to quit should be asked to consider the possibility and encouraged to seek help in the future
  • The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year, where possible
  • Monitoring systems should be set up to ensure health professionals have access to information on the current smoking status of their patients.This should include information on: a) the most recent occasion on which advice to stop was given, b) the nature of advice offered, and c) the response to that advice

NICE states that unless there are exceptional circumstances, all smokers should be advised to quit, not merely those presenting with a smoking-related disease.

People not ready to quit should be asked to think about the possibility of quitting and encouraged to seek help in the future.

Those ready to quit should be offered intensive support and pharmacotherapy (nicotine replacement therapy or bupropion). Support would normally be provided by referral to the local NHS stop smoking service but if this were unavailable or refused by the patient, pharmacotherapy and additional support should still be given where possible.

Although aimed particularly at GPs, the guidance applies to all health professionals, including nurses in primary and community care, pharmacists, dentists and hospital clinicians.

Cost-effectiveness of brief interventions

In developing the guidance, NICE conducted a detailed review of the research evidence on brief interventions for smoking cessation, together with an economic appraisal of cost-effectiveness. This analysis demonstrated that brief interventions conducted by GPs and nurses in all settings in all age groups generated quality-adjusted life year (QALY) gains at low cost.

The cost per QALY tends to increase as the patient's age increases, but brief interventions to a 60-year-old cohort are still cost-effective.

Table 1 illustrates the cost-effectiveness of a GP brief intervention lasting 1 minute delivered to patients between 30 and 60 years of age.

Table 1: Cost-effectiveness of a GP brief intervention lasting 1 minute
Age Cost per QALY over and above control (discounted at 3.5%)
Male Female
30 £127 £115
40 £127 £122
50 £166 £169
60 £322 £335
Reproduced by kind permission of the National Institute for Health and Care Excellence

 

The cost per QALY of between £115 and £335 is very low compared with other NHS interventions, and well within the cost-effectiveness threshold of £20,000 per QALY used by NICE in technology appraisals.8

NICE has developed tools to help organisations implement this guidance.

Implementation tools
NICE has developed tools to help organisations implement Brief interventions and referral for smoking cessation in primary care and other settings.These are available to download from the NICE website: www.nice.org.uk

Costing tools:
     Costing report to estimate the national savings and costs associated with implementation
     Costing template to estimate the local costs and savings involved

Implementation advice on how to put the guidance into practice and national initiatives which support this locally.
Audit criteria to monitor local practice.

The challenge for GPs

The importance of brief interventions for smoking cessation lies in their large reach. A small investment of time spent encouraging smokers to quit and pointing them in the direction of treatment translates to a large population health benefit if applied to all smokers.

For example, in a medium-sized general practice with 7000 patients and about 1500 smokers, there are likely to be as many as 500 smokers ready to make an immediate quit attempt if offered help. Assisting even a small proportion of these smokers to quit would bring enormous health benefits.

The first step in implementing the NICE guidance is to ensure that smoking is treated as a 'vital sign' and recorded routinely. The second step is for practitioners to familiarise themselves with the treatment options available, including referral to the local NHS stop smoking service. There should then be a low threshold for raising the issue of smoking with patients.

It can take as little as 30 seconds to ask a smoker if he or she would like to stop, to offer encouragement and to refer on for treatment. This will be well received by most patients, provided that the intervention is supportive and non-judgmental.

The nGMS contract for general practice provides incentives for this work. Table 2 lists all the indicators related to smoking included in QOF2, which together contribute 87 points.

Table 2: Smoking indicators in QOF2
Disease/indicator no
Clinical Indicator
Points
Payment stages
 
 
 
Min (%)
Max (%)
SMOKING 1
% of patients with any or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD or asthma whose notes record smoking status in the previous 15 months. Except those who have never smoked where smoking status need only be recorded once since diagnosis
33 40 90
SMOKING 2
% of patients with any or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD or asthma who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months
35 40 90
ASTHMA 3
% of patients with asthma between the ages of 14 and 19 in whom there is a record of smoking status in the previous 15 months
6 40 80
RECORDS 22
% of patients over 15 years whose notes record smoking status in the past 27 months, except those who have never smoked where smoking status need be recorded only once
11 40 90
INFORMATION 5
The practice supports smokers in stopping smoking by a strategy which includes providing literature and offering appropriate therapy
2    

Conclusion

In an environment of evidence-based treatment and cost control, brief interventions and referral for smoking cessation stand out as one of the most highly cost-effective uses of NHS resources. This NICE public health guidance should give GPs and others working in primary care the confidence to play their part in ensuring that as many smokers as possible take advantage of the treatment services now available to assist quitting. A relatively small investment of time and energy in helping smokers to quit can reap enormous benefits for patients and for the practice.

 

Guidelines in Practice, June 2006, Volume 9(6)
© 2006 MGP Ltd
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  1. 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.
  2. 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): 1519-28.
  3. 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.
  4. Royal College of Physicians. Working Party Report. Nicotine Addiction in Britain – report of the Tobacco Advisory Group. London: RCP, 2000.
  5. Office for National Statistics. Lader D, Meltzer H. Smoking Related Behaviour and Attitudes, 2002. London: The Stationery Office, London, 2003.
  6. National Institute for Clinical Excellence. Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation. NICE Technology Appraisal Guidance. No. 39. London: NICE, 2002.
  7. Department of Health. Smoking Kills: a White Paper on Tobacco. London: The Stationery Office, 1998.
  8. National Institute for Health and Care Excellence. Social Value Judgements. Principles for the development of NICE guidance. London: NICE, 2005.