Smoking cessation is one of the better-researched areas of healthcare. In December 1998, national guidelines based on research findings current at the time were published in the journal Thorax.
They were entitled 'Smoking cessation guidelines for health professionals. A guide to effective smoking cessation interventions for the health care system',1 and were accompanied by another paper 'Guidance for commissioners on the cost-effectiveness of smoking cessation interventions'.2
Both were funded by the Health Education Authority (HEA), and the lead authors of the cost-effectiveness guidance were from the Centre for Health Economics, University of York.
The guidelines were launched in January 1999 at almost the same time as the UK Government launched a White Paper on tobacco control,3 which announced funding for the development of new treatment services for dependent smokers.
Partly because of this development, and because of the intervening launch of the new drug, bupropion (amfebutamone), the guidelines (but not the cost-effectiveness guidance) have already been updated, this time as a paper in Thorax in December 2000,4 funded by the HEA's replacement, the Health Development Agency (HDA).
Why were new guidelines needed?
The smoking cessation guidelines were developed in the hope of bringing a more structured and evidence-based approach to helping dependent smokers stop, and because of the evidence, from HEA surveys, that many opportunities to advise and support smokers in need of support were not being exploited.
One survey found that only about 29% of smokers who had seen their GP in the previous year could remember being given advice on smoking, and for pregnant smokers the figure was 39%.1
Even if these figures are regarded as encouraging, and of course they do not reveal the true rates of advice-giving, they still leave plenty of room for improvement.
The authors of the guidelines also felt that although there was a huge body of evidence supporting smoking cessation interventions, the case was not really accepted by Government or by commissioners at health authority level.
This is where the cost-effectiveness evidence was important, countering the impression that it is not really worth trying to help smokers stop because the success rates are so low.
Some of the cessation rates are low in absolute terms, but because the interventions are so simple in principle, and so cheap, and because the health gains from stopping smoking are so great, they are an extremely cost-effective means of improving health.
How robust is the evidence for helping smokers stop?
The earliest treatment studies from the last century date from the 1950s, and in the 1960s and 1970s behavioural scientists developed a large body of research, which was added to by the invention and development of nicotine gum in the late 1960s and early 1970s.
Nicotine gum (now included in the group of treatments called nicotine replacement therapy [NRT]) was researched intensively during the 1970s and the first randomised double-blind placebo-controlled trial, which established that it worked, was published by Russell's group in 1982.5
Russell had already shown in 1979 that very brief advice from a GP, with the offer of follow-up, persuaded 5% to stop at one-year follow-up (compared with 0.3% in the control group).6 By the late 1980s there were hundreds of published studies on smoking cessation.
The English guidelines (there are now also Scottish guidelines) were themselves inspired by the US guideline,7 and have in turn been reflected in the development of core recommendations for healthcare systems throughout Europe by the World Health Organization.
All these guidelines are based on several thousand articles and about 300 randomised controlled trials. The English guidelines additionally draw on the systematic reviews produced by the Cochrane Library Tobacco Addiction Review Group.
Clearly, the evidence base for helping dependent smokers stop is huge and robust. The recommendations (summarised in Figure 1,below) in the guidelines have been graded according to the strength of evidence as indicated in Table 1 (below).
|Figure 1: Summary of the recommendations from the updated English smoking cessation guidelines4*|
|* Adapted from West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax 2000; 55;987-99, by kind permision of the BMJ Publishing Group.|
|Rating||Strength of evidence|
|A||Many well-designed randomised controlled trials directly relevant to the recommendation, yielding a consistent pattern of findings|
|B||Some evidence from randomised controlled trials, but not optimal. More interpretation of the evidence was needed. For example, there were not many randomised controlled trials, their results were not consistent, they were not directly relevant to the recommendation. They may not have been directly relevant because, for example, the study population was different.|
|C||No randomised controlled trials but the issue is important enough to merit a recommendation which is based on published evidence and expert opinion of the authors and reviewers.|
|In some cases the recommendation is not a matter of empirical evidence but is a prerequisite for another recommendation that is supported by the evidence. In this case, the strength of evidence is also derived from the related recommendation.|
|* Adapted from West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax 2000; 55: 987-99, by kind permission of the BMJ Publishing Group.|
Effectiveness and cost-effectiveness
The guidelines recommend that an integrated smoking cessation strategy be implemented, including brief opportunistic advice, pharmacological treatments, and the offer of more intensive specialist support where appropriate.
Brief opportunistic advice from a physician helps about 2% of smokers to stop and stay stopped, over and above the number who would have done so without the intervention.8 All the figures given here are over and above rates in the control group.
More intensive face-to-face support from a specialist helps about 7% to stop,4 and the cessation rates from NRT and bupropion added to behavioural support range from about 13% to 19%. 4
Even the low success rates achieved by brief advice delivered opportunistically are hugely worthwhile in reducing disease and the risk of death, and improving health.
Peto and Lopez have shown that population health gain is achieved most quickly by getting adults to stop, rather than by trying to prevent children from starting, and that the lifetime risk of dying as a result of smoking is one in two, i.e. 50%.9
Thus, for each two smokers you help to stop, you save a life, or quite a few years of it at least. Most of your patients, especially those in their 50s and 60s, perhaps looking forward to seeing their grandchildren grow up, would value this enormously.
When intensive behavioural support and pharmacotherapy are given together by trained, dedicated specialists, cessation rates are impressive and very cost-effective.
The original English guidelines estimated the cost-effectiveness of producing one extra life year, for a range of smoking cessation interventions. The most expensive intervention, which included brief advice followed by intensive specialist support including the offer of NRT, cost less than £1 000 per life year gained.
This compares with an informal benchmark of around £5 000–10 000 used by many health economists and policy makers to represent good value, and £17 000, which was the average cost per life year saved in one review of more than 300 medical interventions.2
Improving best practice
The UK White Paper on tobacco control3 and the 3 years 'ring-fenced' money (April 1999 to March 2002), provided by the UK Government to get treatment services for smokers up and running, have made the UK strategy one that much of the world is watching.
Each health authority is supposed to have a full-time smoking cessation coordinator,10 who is responsible for building an effective, integrated service for all smokers who need help in stopping.
Targets have been set by the Government,11 who have also made clear that these targets are long term, and will be built into subsequent guidance, irrespective of the existence of ring-fenced funding.
Aspects of the new services have been specified in the new NHS Plan,12 the National Service Framework for CHD,13 and the NHS Cancer Plan.14
Perhaps one main concern is that all those responsible for developing these services, which includes, crucially, PCGs and PCTs, do not stray too far from the evidence base.
The updated guidelines make it clear that intensive support, e.g. to groups of smokers, should only be given by practitioners trained and paid to do it (this is what is meant by 'specialist' support).
This point is brought out in the evidence relating to nurses giving smoking cessation support. There is no good evidence that such support can be delivered effectively by nurses who are not properly trained and are trying to fit the work around an already busy schedule.
The guidelines state that it is the training, skills and commitment, rather than the professional discipline (e.g. nurse, psychologist etc.) of the person giving the support, that are important.
It is also important not to repeat the experience of the 1990s, when practices tried to set up groups on their premises. This experience was not generally a success – the catchment is too small to sustain a throughput that keeps the staff who are delivering the service occupied, motivated and experienced.
The key point here is that there is now a huge evidence base showing what works (and what does not), and every health authority should have full-time, dedicated, specialist staff running an expert service for smokers. Staff offering smoking cessation advice should be trained by this service, and have paid, dedicated time to do this work to the highest standards.
We have estimated that if each GP advises just half of his/her smokers to stop in a given year, encourages or prescribes NRT or bupropion, and refers to the specialist service when appropriate, it would take about 20 hours, produce 16 extra life years, and nationally produce an extra 200 000 to 300 000 ex-smokers. Not many health service interventions can match that for effectiveness and value for money.
- Raw M, McNeill A, West R. Smoking cessation guidelines for health professionals. A guide to effective smoking cessation interventions for the health care system. Thorax 1998; 53 (Suppl. 5, Part 1): 1-17.
- Parrott S, Godfrey C, Raw M et al. Guidance for commissioners on the cost-effectiveness of smoking cessation interventions. Thorax 1998; 53 (Suppl. 5, Part 2): 1-35.
- Department of Health. Smoking Kills: A white paper on tobacco. London: The Stationery Office, 1999.
- West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax 2000; 55: 987-99.
- Jarvis MJ, Raw M, Russell MAH, Feyerabend C. A randomised controlled trial of nicotine chewing gum. Br Med J 1982; 285; 537-40.
- Russell MA, Wilson C, Taylor C et al. Effect of general practitioners' advice against smoking. Br Med J 1979; ii: 231-5.
- Fiore MC, Bailey WC, Cohen SJ et al. Smoking Cessation. Clinical Practice Guideline No. 18. Publication no. 96-0692. Rockville: Agency for Health Care Policy and Research, US Department of Health and Human Services, 1996.
- Silagy C. Physician advice for smoking cessation. Cochrane Database Sys Rev 2000; 2: CD000165.
- Peto R, Lopez A. Future worldwide health effects of current smoking patterns. In: Koop CE, Pearson CE, Schwarz MR (Eds). Critical Issues in Global Health. San Francisco: Jossey-Bass, 2000.
- HSC 1999/087. New NHS Smoking Cessation Services. Issued 16 April 1999. Available at: www.ash.org.uk/html/cessation/87hsc.pdf
- Modernising Health and Social Services. National Priorities Guidance 2000/01 – 2002/03. Available at: www.ash.org.uk/html/cessation/npg.pdf
- DoH. The NHS Plan: a plan for investment, a plan for reform. London: The Stationery Office, July 2000.
- DoH. National Service Framework for Coronary Heart Disease. London: The Stationery Office, 2000.
- DoH. The NHS Cancer Plan: a plan for investment, a plan for reform. London: The Stationery Office, September 2000.
- Dr Martin Raw has worked as a consultant in the past few years mainly for the Health Development Agency and the World Health Organization, and has also done some consulting for the manufacturers of smoking cessation products. Professor Robert West has undertaken research and consultancy for, and received travel funds from, the manufacturers of smoking cessation medications. Dr Ann McNeill works as an independent consultant. Her clients include the World Health Organization, the Health Development Agency, London, ASH and professional bodies. She has accepted hospitality from the manufacturers of nicotine replacement products and Zyban.