Landmark smoking guidance will help to reduce tobacco harm

Landmark smoking guidance will help to reduce tobacco harm continued

Who can this guidance help?

Following a robust evaluation of the evidence, including economic and expert reviews, NICE PH45 is the first guidance in the world to recommend that licensed nicotine-containing products can be used to help people to reduce the amount they smoke, especially if they are highly dependent on nicotine.⁴ This includes people who:

• may not be able (or do not want) to stop smoking in one go
• want to stop smoking without necessarily giving up nicotine
• may not be ready to stop but want to reduce the amount they smoke.

The best way for people who smoke to reduce the harm from smoking and to improve their health is to stop smoking completely, and in general the best chance of doing this successfully is still to quit in one step. NICE PH45, however, recognises that for people who have been unable to stop in one step, the new approaches recommended in this guidance can help.

NICE PH45 may also encourage more people to consider reducing how much they smoke, with the support of licensed nicotine-containing products (e.g. NRT patches and gum) and advice from stop smoking services, both of which are proven to be effective.⁶

Stop smoking services provide highly cost-effective interventions to help people stop smoking, and the recommendations in NICE PH45 are intended to support and extend the reach and impact of these existing services. The guidance is clear that any investment in the new harm-reduction approaches recommended should not detract from the effective services currently provided.⁴

For a summary of the harm reduction approaches covered by the guidance, see Box 1, below.

Box 1: Harm reduction approaches covered by the guidance4
Stopping smoking, but using one or more licensed nicotine-containing products as long as needed to prevent relapse Cutting down prior to stopping smoking (cutting down to quit*): with the help of one or more licensed nicotine-containing products (the products may be used as long as needed to prevent relapse) without using licensed nicotine-containing products Smoking reduction: with the help of one or more licensed nicotine-containing products (the products may be used as long as needed to prevent relapse) without using licensed nicotine-containing products Temporary abstinence† from smoking: with the help of one or more licensed nicotine-containing products without using licensed nicotine-containing products.
* Someone gradually reduces the amount of tobacco they smoke with a view to stopping smoking within the next few months. † Abstaining from smoking. This could be for a particular event or series of events, in a particular location, for specific time periods (for example, while at work, during long-haul flights or during a hospital stay), or even for the foreseeable future. (The latter might include, for example, abstinence while serving a prison sentence or while detained in a secure mental health unit.) NICE. Tobacco: harm-reduction approaches to smoking. Public health guidance 45. NICE, 2013. Available at: www.nice.org.uk/PH45. Reproduced with kind permission.

Landmark smoking guidance will help to reduce tobacco harm continued

NICE recommendations

NICE PH45 makes a wide range of recommendations that cover a number of aspects, including:⁴

• raising awareness of licensed nicotine-containing products
• choosing a harm-reduction approach
• behavioural support
• advising on, and supplying, licensed nicotine-containing products
• follow-up appointments
• commissioning stop smoking services
• education and training for practitioners.

Some of these recommendations are summarised below.

Raising awareness of licensed nicotine-containing products

The guideline recommends that:⁴

• organisations responsible for tackling tobacco use (e.g. stop smoking services and local authorities) should provide information for the public, highlighting licensed nicotine-containing products as an effective way of reducing the harm from tobacco for both the person smoking and those around them
• training bodies (e.g. local education and training boards) should include the principles and practice of tobacco harm reduction (as outlined in NICE PH45) in all relevant training for practitioners
• certain national and local organisations (including professional bodies with a public health responsibility, health and wellbeing boards, and organisations providing practitioner training in reduction of smoking harm) should provide self-help materials to meet the needs of groups where smoking prevalence
• and tobacco dependency is high
• tobacco retailers, and retailers of licensed nicotine-containing products, should display licensed nicotine-containing products in shops and supermarkets and on websites selling cigarettes and tobacco products.

Choosing a harm-reduction approach

Stop smoking advisers and healthcare professionals should:⁴

• advise people to stop smoking in one step, but suggest a harm-reduction approach for people who are not ready (or are not able) to stop in one step
• ensure people know that licensed nicotine-containing products (e.g. nicotine patches, gum, or spray) make it easier to:
  • cut down smoking prior to stopping
  • reduce the amount they smoke.

Use of licensed nicotine-containing products also:

• helps to avoid compensatory smoking
• increases the chances of a person stopping smoking in the longer term.⁴

Behavioural support

Advisers should discuss reduction strategies, which may include:⁴

• increasing the time interval between cigarettes
• delaying the first cigarette of the day
• choosing periods during the day (or specific occasions) when the person will not smoke.

Advising on, and supplying, licensed nicotine-containing products

Advisers and healthcare professionals should:⁴

• offer all types of licensed nicotine-containing products to people who smoke, as part of a harm-reduction strategy
• offer products either singly or in combination, according to the individual’s preference and level of dependence (e.g. patches could be offered with gum or lozenges)
• advise people that using a combination of products is likely to be more successful than using just one, particularly if they are highly dependent smokers.

Landmark smoking guidance will help to reduce tobacco harm continued

NICE implementation tools

NICE has developed the following tools to support implementation of Public Health guidance 45 (PH45) on Tobacco: harm-reduction approaches to smoking. The tools are now available to download from the NICE website: www.nice.org.uk/PH45 NICE support for commissioners Costing report  Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline. Costing template  A costing template helps services in estimating the local cost of implementing guidelines and public health guidance. This template allows individual NHS organisations and local health economies to quickly assess the impact guidance will have on local budgets. NICE support for service improvement systems and audit Baseline assessment tool The baseline assessment tool is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.

Follow-up appointments

The person should be invited to follow-up appointments to review progress, when:⁴

• exhaled carbon monoxide level should be measured at appropriate intervals to gauge progress and help motivate the person
• the person should be asked whether daily activities (e.g. climbing the stairs, walking uphill) have become easier.

Feedback should be used at these appointments to prompt discussion about the benefits of reducing smoking and (where appropriate) to encourage a further reduction in smoking, or stopping completely. People who have not achieved their goals should be:⁴

• encouraged to try again
• asked whether they would like to:
• continue using the same licensed nicotine-containing product
• try a different one (or a different combination of products).

Landmark smoking guidance will help to reduce tobacco harm continued

Definitions

In NICE PH45 (and this article), the phrase ‘licensed nicotine-containing products’ refers only to the use of licensed nicotine-containing products that have been given marketing authorisation by the Medicines and Healthcare products Regulatory Agency (MHRA) for use as a smoking cessation aid and for tobacco harm reduction. Authorisation by the MHRA ensures these products:

• are effective
• deliver nicotine safely
• are manufactured to a consistent quality.

Currently, NRT products are the only type of licensed nicotine-containing product. They include:⁴

• transdermal patches
• gum
• inhalation cartridges
• sublingual tablets
• nasal spray.

The MHRA announced in June 2013 that it intends to start regulating electronic cigarettes.⁷ So, if in future any electronic cigarettes or other new nicotine-containing products receive a licence from the MHRA to show that they are safe, effective, and quality assured, then they also will be covered by the recommendations in NICE PH45.

Conclusion

The cost to the NHS in England of treating smoking-related illnesses is an estimated £2.7 billion a year.⁸ As 1 in 5 adults in England smokes, and around two-thirds of people who smoke say they would like to quit, PH45 provides an important opportunity to reduce the harm associated with smoking tobacco.⁴

GP commissioning take home messages for England
written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead NICE PH45 is public health guidance and the lead responsibility for implementing it lies with public health departments, now hosted in local authorities The key initiative to reduce the harm from smoking, in addition to promoting smoking cessation, should prompt a high level review in HWBs, and local recommendations for implementation should be expressed in the Health and Wellbeing Strategy Clinical commissioning groups, as statutory members of HWBs, should look to build specifications for smoking harm-reduction into contracts with local providers Local authorities are now responsible for commissioning smoking reduction initiatives from primary care services like GPs, pharmacies, and dentists; these services are likely to be commissioned through local contracts From April 2014, local enhanced services cease and will be called ‘contracted services’. Clinical commissioning groups and local authorities will need to review, respecify, and reprocure any current smoking reduction local enhanced services; these could be offered through competitive tender or ‘any qualifed provider’.
PH=public health; HWB=health and wellbeing board

Landmark smoking guidance will help to reduce tobacco harm continued

Key points

Nicotine inhaled from smoking tobacco is highly addictive but it is primarily the toxins and carcinogens in tobacco smoke, not the nicotine, that cause illness and death. The best way to reduce these illnesses and deaths is to stop smoking (ideally in one step) There are, however, other ways of reducing the harm from smoking, even though this may involve continued use of nicotine NICE has published landmark public health guidance (PH45)4 to reduce tobacco-related harm for people who do not feel able to stop smoking in one step This guidance aims to help people, particularly those who are highly dependent on nicotine, who may: not be able (or do not want) to stop smoking in one step want to stop smoking, without necessarily giving up nicotine not be ready to stop smoking, but want to reduce the amount they smoke Harm-reduction approaches may or may not include temporary or long-term use of licensed nicotine-containing products NICE PH45 is particularly aimed at people involved in providing advice on quitting smoking, including those working in smoking cessation services, and is also for: commissioners, managers, and practitioners with public health as part of their remit organisations that provide education and training manufacturers and retailers of licensed nicotine-containing products.

References

1. Health and Social Care Information Centre. Statistics on smoking: England, 2012. Available at:
2. Action on smoking and health (ASH). The economics of tobacco. Available at:
3. Lindson N, Aveyard P, Hughes J. Reduction versus abrupt cessation in smokers who want to quit. Cochrane Database of Systematic Reviews 2010, Issue 3. Art No: CD008033. Available at:
4. NICE. Tobacco: harm-reduction approaches to smoking. Public health guidance 45. NICE, 2013. Available at: www.nice.org.uk/PH45 (accessed 11 November 2013). 
5. Shiffman S, Ferguson S, Strahs K. Quitting by gradual smoking reduction using nicotine gum: a randomized controlled trial. Am J Prev Med 2009; 36 (2): 96–104.e1.
6. Smoking in England website. STS documents. Smoking and smoking cessation in England. Findings from the Smoking Toolkit Study 2011. STS120501, 2013. Available at: www.smokinginengland.info/sts-documents/
7. MHRA website. Nicotine containing products. (accessed 22 October 2013).
8. Callum C, Boyle S, Sandford A. Estimating the cost of smoking to the NHS in England and the impact of declining prevalence. Health Econ Policy Law 2011; 6 (4): 489–508. G

Dr Tonya Gillis

Media Relations Manager

National Institute for Health
and Care Excellence