NICE consults on draft guidance to help people who can't quit smoking in one step

How to reduce the harm from tobacco use for people who don't feel able to quit smoking in one step is covered in National Institute for Health and Care Excellence (NICE) draft guidance, which opens for public consultation today (Wednesday 24 October).

The NICE public health draft guidance makes provisional recommendations for using licensed nicotine-containing products to support people who want to cut down gradually before quitting, those who want to smoke less and those who want to stop smoking for a specific period of time, such as during the working day.

The cost to the NHS in England of treating smoking-related illnesses is an estimated £2.7 billion a year. The harm caused by smoking is due to the toxins and carcinogens in tobacco smoke, not nicotine. However, nicotine is addictive, which is why people find it so difficult to stop smoking. One in five adults in England smoke, with the prevalence highest among 20 to 34 year olds where over one in four smoke. Around 67% of people who smoke say they'd like to quit.

Professor Mike Kelly, Director of the NICE Centre for Public Health Excellence, said: “Smoking tobacco is responsible for over 79,000 deaths in England each year and children's vulnerability to second-hand smoke is well documented. If you are a smoker, quitting smoking is the best way to improve health, and quitting in one step is most likely to be successful. However some people - particularly those who are highly dependent on smoking - may not feel able (or don't want) to do this. Harm reduction approaches provide an alternative choice, and are more successful when used with licensed nicotine-containing products. Methods such as ‘cutting down to quit' may appeal to people who feel unable to quit in one step. ‘Smoking less' is an option for those who are not interested in quitting smoking, although the health benefits are not clear. However, for some people this can kick-start a gradual change in behaviour that eventually leads them to quit smoking.

“Among the provisional recommendations, this draft guidance says that health professionals should advise people who smoke and want to try cutting down to quit, or smoke less, that this is easier when using licensed nicotine-containing products. Advisors should also reassure people that licensed nicotine-containing products are a safe and effective way of reducing the harm from cigarettes, and that nicotine replacement therapy (NRT) products have been shown as safe for up to 5 years' use. Whatever approach people wish to try, they should be advised that there are no circumstances when it is safer to smoke than to use NRT products and experts believe that lifetime use of NRT will be considerably less harmful than smoking.

“This draft NICE guidance will, once finalised, be useful in setting out how different harm reduction options can help tackle tobacco use for individuals who smoke. We hope that it will also raise wider awareness of the important role of licensed nicotine containing products such as nicotine replacement therapies, in helping people cut down, and then ideally stop using tobacco. We look forward to receiving comments on our draft recommendations from health professionals, local government and communities to help inform the development of this guidance.”

The NICE draft recommendations include:

  • Stop smoking advisers and health professionals should offer NRT products on prescription to people who smoke, as part of a harm-reduction strategy. All types of NRT should be on offer, either singly or in combination, according to the individual's preference and level of dependence. (For example, patches could be offered with gum or lozenges). Advise people that using more than one product is more likely to be successful particularly for more dependent smokers
  • Advisers should find out about the person's smoking behaviour and level of dependence and use this information to help the person set goals and discuss reduction strategies. This may include increasing the time interval between cigarettes, delaying the first cigarette of the day or choosing points during the day, or specific occasions, when they will not smoke. Follow up appointments to review progress should also be offered
  • Tobacco retailers should display licensed nicotine-containing products in shops and supermarkets, and on websites selling cigarettes and tobacco products
  • Advisers should inform people who smoke that some nicotine-containing products (for example, electronic cigarettes) are not currently regulated by the Medicines and Healthcare products Regulatory Agency and so their safety and quality can't be assured. However, tell them that these products are likely to be less harmful than cigarettes.

The draft guidance, 'Tobacco: harm-reduction approaches to smoking', will be open for public consultation from 24 October until 19 December.


Notes to Editors

About the draft guidance, ‘Tobacco: harm-reduction approaches to smoking'

1. Please contact the NICE Press Office for an embargoed copy of the draft guidance.

2. Harm reduction involves continued use of tobacco or nicotine, while reducing the harm caused by tobacco to the smoker and others. The options addressed in this guidance are:

  • Quit smoking in one step with the help of one or more licensed nicotine-containing products and continue to use these products as a substitute, possibly indefinitely.
  • Cut down prior to quitting (with a view to stopping smoking within the next few months), by smoking fewer cigarettes or inhaling or smoking less of each cigarette, with or without the help of one or more licensed nicotine-containing products.
  • Smoke less, by smoking fewer cigarettes, inhaling less or smoking less of each cigarette, with or without the help of one or more licensed nicotine-containing products.
  • Temporarily abstain with or without the help of one or more licensed nicotine-containing products. This could be for a specific occasion (for example, while in hospital), for regular events (for example, when at work or in the home), or while confined in an environment where smoking is prohibited (for example, in a prison or secure mental health facility).

3. The draft guidance notes that investment in approaches to reduce the harm caused by tobacco should not detract from the provision of existing stop smoking services, which provide highly cost-effective interventions to help people quit in one step. Rather, the recommendations in this guidance are intended to support and extend the reach and impact of existing service.

4. Licensed nicotine-containing products have been given marketing authorisation by the Medicines and Healthcare products Regulatory Agency (MHRA). Currently, nicotine replacement therapy (NRT) products are the only type of licensed nicotine-containing product. They include: transdermal patches, gum, inhalation cartridges, sublingual tablets and a nasal spray.

5. For people cutting down to quit, or smoking less, using licensed NRT products are likely to reduce compensatory smoking behaviour, such as inhaling smoke more deeply.

6. Other nicotine-containing products, such as electronic cigarettes and topical gels, were not covered by MHRA regulation at the time of publication of this draft guidance. An MHRA decision is expected in early 2013.

7. Tobacco smoking remains the single greatest cause of preventable illness and early death in England, accounting for 79,100 deaths among adults aged 35 and over in 2011 (NHS Information Centre 2012). The overall financial burden to society has been estimated at £13.74 billion a year. This includes both NHS costs and loss of productivity due to illness and early death (Nash and Featherstone 2010).

8. People from routine and manual occupational backgrounds are almost twice as likely to smoke as those from managerial or professional backgrounds (27% versus 13%) (NHS Information Centre 2012). In 2010, those aged 20-24 and 25-34 reported the highest prevalence of cigarette smoking (28% and 26% respectively, NHS Information Centre, 2012).

9. Most people attempt to quit without help. But only around 4% who quit without using behavioural or pharmacological therapy are successful for a year or longer (Hughes et al. 2004). This compares to about 15% of those who quit using the NHS Stop Smoking Service (Ferguson et al. 2005).

10. The use of products containing tobacco as a means of ‘harm reduction' is outside the scope of this guidance. This means that ‘reduced exposure cigarettes' and ‘smokeless tobacco' are excluded.

11. This guidance does not cover pregnant women and maternity services.

12. NICE public health guidance applies to England and is not mandatory.

About NICE

13. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health.

14. NICE produces guidance in three areas of health:

  • public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
  • health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
  • clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

15. NICE produces standards for patient care:

  • quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
  • Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients
  • Commissioning Outcomes Framework - NICE develops the potential indicators for the COF, the scheme starting in 2013, which will help measure the health outcomes and quality of care commissioned by Clinical Commissioning Groups.

16. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates high quality guidance and evidence-based information to help professionals deliver the best patient care through NHS Evidence.

This page was last updated: 24 October 2012

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.