Dr Tim Coleman reviews guidance recommendations for primary care on strategies to support smokers to quit, and provision of NHS stop smoking services

Smoking is still the biggest reversible cause of ill health in the UK and a massive public health problem; approximately 22% of the population smoke.1 Annually, over 80,000 people in the UK die from smoking-related diseases, so the eradication of smoking is a huge priority for the NHS.2 There are three clinical guidelines on smoking that are very relevant to primary care:

  • NICE—Brief interventions and referral for smoking cessation in primary care and other settings3
  • NICE—Smoking cessation services in primary care, pharmacies, local authorities and work places, particularly for manual working groups, pregnant and hard to reach communities4
  • Department of Health—NHS stop smoking services: service and monitoring guidance 2010/11.5

This article discusses the above pieces of guidance and the likely future changes that might occur in response to accruing research evidence and the planned reorganisation of the NHS.

Brief interventions and referral

The NICE guidance on brief interventions and referral was first published in 2006;3 the document was reviewed in 2010 but was not updated because there was insufficient new research evidence. Brief smoking cessation interventions are simple, evidence-based approaches that GPs and other primary care healthcare professionals can use in their routine consultations to help smokers to quit. These can last for up to 10 minutes (a complete GP consultation), but are usually much shorter and may involve one or more of the following:3,6

  • Simple advice about stopping
  • An assessment of motivation to stop
  • Offering cessation-orientated pharmacotherapy or referral to NHS stop smoking services (NHS SSS)
  • Giving out self-help materials (e.g. leaflets).

The recommendations that relate to primary care are summarised in Box 1 (below). NICE recommendations on prescribing smoking cessation treatments (pharmacotherapy) are discussed below

Box 1: NICE ‘brief interventions’ guidance of relevance to primary care3
  • All smokers should be advised to quit unless there are exceptional circumstances
  • Smokers should be asked how interested they are in quitting. Advice should be sensitive to individuals' preferences
  • GPs should advise all smokers to quit when they attend a consultation. Those who want to stop should be offered referral to an NHS stop smoking service. If they do not accept referral, they should be offered pharmacotherapy in line with the NICE guidance on smoking cessation services. The smoking status of individuals who are not ready to stop should be reviewed annually
  • Primary care nurses should advise and refer smokers (as per above recommendation). Appropriately trained nurses may deliver intensive behavioural support for smoking cessation (as is available from stop smoking services)
  • Smoking cessation advice and support should be available in community, primary, and secondary care settings for all smokers
  • Monitoring systems should be used to give healthcare professionals access to information on patients' smoking status and the most recent occasion on which advice to stop was given.

 

Quality and outcomes framework
Some of the brief interventions recommended by NICE are firmly integrated into primary care clinical practice. To comply with the quality and outcomes framework (QOF), which was introduced as part of the 2004 GMS contract,7,8 GPs should:

 

  • record the smoking status of most patients
  • advise smokers to not smoke
  • refer individuals who want help stopping to NHS SSS.

The QOF particularly incentivises interventions delivered to patients who have specified chronic diseases and this may also have increased GPs’ propensity to intervene with all smokers.9 Since the QOF was introduced, GPs have begun to record both the smoking status of patients and the provision of brief advice to smokers more frequently in medical records.10 However, this increased documentation of brief intervention delivery has not been accompanied by a concomitant increase in prescribing of nicotine addiction treatments,10 leaving the quality of brief interventions recorded in patients’ notes as a result of the QOF open to question.11 With more brief interventions apparently being delivered (i.e. recorded in patients’ notes), it is to be expected that GPs would identify greater numbers of motivated smokers who wish to try quitting, and for a proportion of such smokers to be prescribed effective pharmacotherapies to help them stop smoking. Unfortunately, as there has been no increase in prescribing since the QOF,10 this does not appear to be happening.

Future changes
As brief interventions in primary care are not currently being extensively researched, the NICE guidance in this clinical area is unlikely to change substantially in the near future. However, at least one major primary care trial is investigating how clinicians counsel patients to change their behaviour,12 and together with other research on the subject, the study results may enhance the evidence base on how to deliver brief interventions in routine consultations, which GPs find particularly challenging.13,14 However, it is likely to be some time before the evidence base is strong enough to warrant updating recommendations on brief interventions with respect to how clinicians should deliver these so that they have maximal impact.

Smoking cessation services

There is very strong evidence supporting the use of pharmacotherapy15–17 and/or intensive behavioural support18 for smoking cessation, and the detailed NICE guidance on smoking cessation services spells out how the NHS should provide these effective interventions.4 A key recommendation is that the NHS should commission stop smoking services for all smokers. This reflects the fact that such services can potentially quadruple a smoker’s chances of stopping permanently in any one quit attempt by providing effective behavioural support with smoking cessation pharmacotherapy.19,20

The NICE guidance recognises that individual smokers may respond maximally to very different kinds of support and lists a menu of effective interventions that all NHS SSS should provide (see Box 2, below).4 Prescribers are advised not to consider any one treatment as ‘first-line’ therapy, but to be guided by the patient’s preferences when selecting from recommended drug treatment options (see Box 3, below). As there is insufficient space to discuss all recommendations mentioned in this guidance and as the NICE approach to pharmacotherapy is likely to change over the coming years, this article focuses on prescribing.

Abrupt cessation versus other methods
NICE recommends planning for cessation attempts, setting a quit date, and making an abrupt effort to achieve abstinence in almost all circumstances. This abrupt cessation model requires nicotine replacement therapy (NRT) to start on the quit date itself or bupropion or varenicline, which require pre-loading, to be started 1 or 2 weeks earlier.4 It is advised that treatments are initially issued for no more than 2 weeks after planned quit dates; consequently, the first NRT prescription issued within a quit attempt should be for a fortnight’s supply and varenicline and bupropion scripts should be for 3–4 weeks. After a failed abrupt cessation attempt, NICE suggests that, unless special circumstances prevail, smokers should wait 6 months before receiving any repeat courses of treatment; however, no guidance is given as to how special circumstances should be defined.4

Updating NICE guidance
The NICE guidance is relatively restrictive in how it recommends that prescribed medication should be used. There is now strong evidence that nicotine-assisted reduction in smoking (NARS), a non-abrupt cessation method (sometimes called ‘cut down to quit’) is also effective.21,22 Smokers who adopt a NARS approach are encouraged to use NRT to replace some cigarettes and reduce their daily number smoked. They are not expected to try to stop or even to want to do so immediately, but are encouraged to do this at a later date, after long-term support with smoking reduction. Despite not being instructed or encouraged to stop smoking immediately, the NARS approach is effective at promoting smoking cessation among a group of smokers who would not usually be considered for NHS support (i.e. those not currently motivated to quit).21,22

However, current guidance only supports using a NARS approach during clinical trials and not as part of routine clinical practice4 and perhaps this is one recommendation that is overdue for revision? Similarly the recommendation that ‘failed quitters’ should wait 6 months or more after unsuccessful quit attempts before receiving further NHS support is not supported by available research evidence.23 This is another NICE pronouncement that probably should be altered when the guidance is reviewed.

Research areas in smoking cessation
Future guidance may also need to assess the use of smoking cessation treatments for ‘relapse prevention’. This involves prescribing extended courses of NRT, bupropion, or varenicline to smokers who have already managed to achieve abstinence in ‘supported’ quit attempts (i.e. using behavioural support and pharmacotherapy).24 These pharmacotherapies are effective at preventing smokers from relapsing back to smoking after standard cessation treatment has finished. Relapse prevention treatment is very cost effective in comparison with other health interventions and could be an important development for the NHS.24,25

Other roles for NRT that are currently being investigated are:

  • the promotion of temporary (i.e. short periods of) abstinence from smoking by people who are unable to quit
  • for nicotine preloading, which is the use of ‘extended pre-treatment’ NRT to enhance quit rates obtained by abrupt cessation methods.

It is currently uncertain whether or not NRT used for temporary abstinence or as ‘preloading’ results in higher quit rates, but this should soon become more apparent and may prompt further consideration by NICE.

Finally, in the next few years, the results from three trials investigating the efficacy and safety of NRT in pregnancy will be reported and these could, potentially, provide NICE with empirical research data to make more robust recommendations about prescribing NRT for pregnant women.26

 

Box 2: NICE-recommended interventions for provision by NHS stop smoking services4

  • Individual behavioural counselling—scheduled face-to-face meetings between the smoker and a counsellor trained in smoking cessation
  • Group behavioural therapy—weekly meetings for the first 4 weeks of a quit attempt where smokers receive information, advice, encouragement, and behavioural intervention
  • Pharmacotherapies for smoking cessation
  • Self-help materials—any manual or structured programme (in written or electronic format) that can be used by individuals to quit smoking without the help of healthcare professionals
  • Telephone counselling and quitlines—encouragement and support over the telephone for anyone who smokes and wants to quit, or who has recently quit
  • Mass-media campaigns—using combinations of TV, radio, and national newspaper advertising.

 

Box 3: Selected NICE recommendations for use of pharmacotherapy4
  • Offer NRT, bupropion, or varenicline to people who are planning to stop smoking
  • Do not favour one therapy over another. The clinician and patient should choose the one that seems most likely to succeed
  • Consider offering a combination of nicotine patches with another form of NRT (e.g. gum, lozenge, or spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past
  • Do not offer NRT, bupropion, or varenicline together in any combination
  • Varenicline or bupropion may be offered to people with unstable vascular disorders, subject to clinical judgement
  • Varenicline and bupropion should not be offered to those aged <18 years or women who are breastfeeding or who are pregnant
  • Before recommending the use of NRT, the risks and benefits should be explained to people aged 12–17 years, women who are pregnant or breastfeeding, and people who have unstable cardiovascular disorders.
NRT=nicotine replacement therapy

NHS stop smoking services: service and monitoring guidance 2010/11

The best practice service and monitoring guidance on NHS SSS was developed by the Department of Health (DH) and partner academics and is aimed at commissioners and managers of such services.5 It is evidence-based, reaching broadly similar conclusions on the provision of interventions by NHS SSS as the NICE guidance on smoking cessation services.4,5 In contrast to the NICE guidance, the DH document lists almost all of the cessation interventions that NHS SSS might consider providing and summarises the evidence for each one, however strong or weak. There is also practical information about how NHS SSS should be commissioned to help service commissioners implement NICE guidance.

National Centre for Smoking Cessation Training
The DH guidance highlights a key resource in the form of the new National Centre for Smoking Cessation Training (NCSCT).27 The NCSCT is developing evidence-based national standards for smoking cessation training and competence-based training programmes for smoking cessation workers. Online courses are planned to test knowledge competence and some are already available for NHS staff. Skills-based competences are expected to be taught and assessed using face-to-face training courses with assessments and the NCSCT plan is for practitioners to satisfactorily complete both aspects of training to be eligible for certification.27

Healthy lives, healthy people
At present, NHS SSS are commissioned by primary care trusts (PCTs), however PCTs will be abolished in a planned re-organisation of the NHS in England; how NHS SSS might look in the post-reorganisation landscape is currently unclear. The Government White Paper, Healthy lives, healthy people: Our strategy for public health in England,28 however, shows that smoking remains a public health priority for the coalition Government and details how a new organisation, Public Health England, will work with local authorities to reduce tobacco smoking.28 Although the specifics of how this might be operationalised are awaited, it seems highly probable that the provision of intensive cessation support, which is currently provided via NHS SSS, will fall within the remit of local authorities. Consequently, the three sets of guidance reviewed in this article will remain relevant, despite substantial organisational changes.

Conclusions

The pieces of guidance discussed in this article demonstrate that the NHS treats smoking as a serious threat to the nation’s health and tackling this requires a systematic approach across the whole health service. The NICE recommendations relating to drug treatments are most likely to change in the near future due to the strengthening evidence base for different uses of smoking cessation pharmacotherapy. However, many of the behavioural aspects of smoking cessation management—such as how to deliver brief intervention counselling, whether abrupt or gradual cessation is equally successful, and whether repeated re-treatment of ‘failed quitters’ at shorter intervals is effective or not—are underpinned by relatively little empirical data and research, Results of research on all of these interventions could perhaps have even greater impacts on the effectiveness of smoking cessation treatment in the NHS. Finally, in a time of massive organisational upheaval for the NHS, it is important to remember that smoking is the single most important, reversible cause of ill health in the UK and it remains hugely important to maintain an organised approach towards eliminating it.

 

 


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