Rationale and impact

Overview

The committee were tasked with partially updating recommendations from 2 NICE guidelines about smoking cessation. The aim was to develop a single NICE guideline about smoking cessation that would reflect changes in current practice and commissioning. Some recommendations from the 2006 and 2008 guidelines were not reviewed by the committee as part of this update and these original recommendations have been retained. However, some recommendations have been edited to ensure that they meet current editorial standards, and reflect the current policy and practice context. Because this update is for smoking cessation only, we have not included guidance on smokeless tobacco cessation. Users should consult NICE's guideline on smokeless tobacco: South Asian communities. Other recommendations were reviewed, taking into account any new evidence and expert opinion.

Given the large body of research about smoking cessation, we developed a pragmatic approach to identifying evidence. Evidence was identified through a series of steps. Briefly, these steps involved reviewing high quality systematic reviews conducted by Cochrane, followed by non-Cochrane systematic reviews and then individual studies. The committee used the results of this to update some recommendations, and to identify gaps where further evidence was needed to inform decisions. Gaps identified by the committee included evidence about the use of digital media as an adjunct to other interventions.

The committee considered the body of evidence (published or expert testimony) presented for each review question, and then drafted recommendations based on this evidence and the experiences of the topic experts. More detailed information on how the evidence or testimony was considered by the committee is available in the systematic reviews done to support this guideline. If original recommendations from NICE's guidelines on smoking: brief interventions and referrals and stop smoking services were deleted, the committee discussed these in light of the new recommendations to ensure that no recommendations were deleted without a satisfactory update or reason for deletion.

This committee only discussed evidence linked to recommendations being updated, the original evidence reviews and deliberations of the 2006 and 2008 guideline committees were not reviewed as part of this update process.

See the PH1 and PH10 evidence for recommendations that have been incorporated from previous guidelines.

Economic modelling

A stepped approach was taken to the effectiveness evidence. The effectiveness evidence from 30 different interventions was modelled. Intervention costs ranged from £19 to £763 per person. Intervention effectiveness in terms of people who quit ranged from 9 to 47% and they were all highly cost effective at a threshold of £20,000 per quality-adjusted life year. Additionally, a 2-way scenario analysis that varied the quit rate associated with an intervention and the cost of the intervention showed that even when the lowest quit rate identified in the effectiveness studies (9%) is combined with the most expensive intervention cost (£763 per person), the intervention is still cost effective. Because patient preference is essential for successful intervention, the committee considered any cost-effective intervention to be an option for use.

How the recommendations might affect practice

Smoking is the main cause of preventable illnesses and deaths in England. The estimated annual cost to the economy is more than £11 billion. Of this annual cost, £2.5 billion fell to the NHS (Statistics on smoking, England – 2016 Health and Social Care Information Centre), £5.3 billion to employers, and £4.1 billion to wider society. This last figure is based on the death or absence of people who would otherwise be working and contributing to the economy. Smoking-related ill-health also increases costs for the adult social care system, which are not included here but which are likely to be substantial. For example, the World Health Organization estimates that smoking may be responsible for up to 14% of all cases of Alzheimer's disease, the most common form of dementia.

But if all health and social care workers could identify which of the people they see are smoking and give them information and support to help them quit, these figures could change. In some cases it might lead to people getting help to quit at an earlier stage, preventing smoking-related health problems entirely or stopping them getting worse.

Targeting groups who smoke heavily or who find it most difficult to stop will make the most difference, because they are most at risk of becoming ill or dying. Focusing time and resources where they will make the most difference will also reduce costs for the NHS.

Commissioning and providing stop smoking interventions and services to meet local needs

The discussion below explains how the committee made recommendations 1.1.1 to 1.1.3.

Why the committee updated the recommendations

Government policy changes since the publication of NICE's 2008 guideline on stop smoking services mean that the NHS and local authorities now produce sustainability and transformation plans to jointly meet local health needs. Their priorities for providing care, set out in health and wellbeing strategies, are founded on these plans. The committee agreed that commissioners and managers should use Public Health England's public health profiles, such as the Local Tobacco Control Profiles to find recent data on tobacco use and tobacco-related harm because knowing an area's needs is key. Local government and health services can use these data to plan how to tackle tobacco use and ensure that stop smoking interventions are available for everyone who smokes. Having reliable data will help local authorities allocate funds to local stop smoking services.

Public Health England's public health profiles together with sustainability and transformation plans, and health and wellbeing strategies will provide data on specific groups who are at high risk of tobacco-related harm in the area. Based on topic experts' experience, the committee agreed that some people in these groups are likely to smoke heavily or find it harder to quit than the general population of people who smoke. They are also more likely to have other physical health problems. Stopping smoking can reduce smoking-related complications.

How the recommendations might affect practice

Like NICE's 2008 guideline on stop smoking services, this guideline recommends the provision of stop smoking services and support, so there is no change in the funding implications. The value of support for stop smoking remains strong and the level of funding for this activity should not be reduced. By targeting groups at high risk of harm from smoking, stop smoking services can make a bigger difference and use resources more effectively.

Full details of the evidence and the committee's discussion are in evidence review A.

Monitoring stop smoking services

The discussion below explains how the committee made recommendations 1.2.1 to 1.2.4.

Why the committee updated the recommendations

The committee agreed that stop smoking services that meet the targets are more likely to be funded, even when there are competing demands on local budgets. These targets, which were set because of expert opinion, were recommended in the original 2008 guideline on stop smoking services. The committee agreed that, based on their experience, there was no need to change them.

Quit rates are important because they provide planners with a figure that represents the benefit of a person stopping smoking. Topic experts advising on using carbon monoxide monitoring as a marker for quitting suggested that there was no reason to change the cut-off of 10 ppm recommended in the 2008 guideline. But because there is no universally agreed threshold the committee made a research recommendation on this (research recommendation 2).

Independent monitoring of quit rates and making the results public should ease concern about stop smoking services enhancing their performance results to ensure continued funding.

How the recommendations might affect practice

The recommendations will support current best practice and encourage investment in evidence-based services.

Full details of the evidence and the committee's discussion are in evidence review A.

Evidence-based stop smoking interventions

The discussion below explains how the committee made recommendations 1.3.1 to 1.3.9.

Why the committee updated the recommendations

Evidence showed that all the stop smoking interventions recommended for adults are effective. But to get the most benefit, staff delivering behavioural interventions must be trained to the NCSCT training standard. There was some evidence that NRT helped young people over 12 who smoke, and topic experts on the committee emphasised that young people are more likely to stop smoking when they also get behavioural support.

Topic experts explained that, in their experience, quit rates increase when text messaging is added to behavioural support. Evidence for text messaging alone was not reviewed so the committee did not make a recommendation for this. The text messages should be tailored to the person, give information about the health effects of smoking, provide encouragement, boost self-efficacy, motivate and give reminders of how deal with difficult situations.

How the recommendations might affect practice

All the interventions are clinically effective, cost effective and cost saving to both the NHS and local authorities. Most organisations will not need to change current practice, and support to stop smoking services should remain a priority. Behavioural support in the UK is currently only provided by stop smoking services. If GPs were commissioned to provide this intervention they would be likely to contract this out to the local stop smoking services. Staff working in GP settings currently offer pharmacotherapy plus very brief advice.

Individual behavioural support involves more staff than group behavioural support. But group behavioural support can lead to delays in support for people wanting to quit because they usually need a minimum number of people before they can start. Text messaging is routinely provided in stop smoking services as an opt-out adjunct to behavioural support and because it is cheap it does not need significant investment.

Full details of the evidence and the committee's discussion are in evidence review B.

Engaging with people who smoke

The discussion below explains how the committee made recommendations 1.4.1 to 1.4.4.

Why the committee updated the recommendations

Evidence showed that advice and referral is effective and highly cost effective in helping people to stop smoking. So health and social care workers in primary and community settings should speak to people about their smoking status at every contact. This is particularly important for people from more disadvantaged groups because evidence shows that they have much higher smoking rates and lower than average quit rates. They are also more likely to have respiratory, heart or other chronic conditions caused by, or worsened by, smoking.

Although some staff worry that people who smoke may feel they are being given too much advice, the committee considered that missing the chance to give appropriate advice carried a greater risk of harm. Also, the person may seek advice from other sources that may not be able to guide them to local stop smoking support. Topic experts persuaded the committee that people are more likely to think about stopping when asked in a way that is sensitive to their preferences and needs.

Evidence showed that smoking delays recovery after surgery, so people should stop smoking before having elective surgery. Because this is so important, the committee recommended that people planning surgery be referred for stop smoking support (an opt-out approach) rather than being offered a referral (an opt-in approach).

How the recommendations might affect practice

Asking about smoking status, giving advice and referring to local stop smoking support should be part of routine care. Staff should gain the knowledge and skills to give this care though their basic training and further training provided by their employers.

Full details of the evidence and the committee's discussion are in evidence review E.

Advice on e‑cigarettes

The discussion below explains how the committee and NICE made recommendation 1.5.1.

Why the committee updated the recommendations

People who smoke often ask healthcare practitioners about using nicotine-containing e‑cigarettes, which are increasingly being used for quitting. Because of the misconceptions and confusion about the safety of e‑cigarettes, the committee agreed that advice should be given to allow an informed discussion on using them to stop smoking.

The long-term harms caused by smoking, even in the short term, are well established and are the reason people who smoke are advised to quit. The committee were aware of reports produced by Public Health England (E-cigarettes and heated tobacco products: evidence review) and the Royal College of Physicians (Nicotine without smoke: tobacco harm reduction) stating that the constituents of cigarette smoke that harm health are either absent in e‑cigarette vapour or, if present, are mostly at much lower levels.

However, the committee also concluded that because e‑cigarettes have only been widely available for a short period, the evidence on the long-term impact of their short-term use as well as the long-term health impact of their long-term use was still developing.

The committee were concerned that people who smoke should not be discouraged from switching to e‑cigarettes, and as a result continue to smoke, because the evidence is still developing. Although there is a little evidence on the effectiveness and safety of these as medicinal products, the committee expected that these products are likely to be less harmful than smoking. Although they did not review the evidence detailed in the reports, they noted the recent reviews by Public Health England and others that stated that e‑cigarettes are substantially less harmful than smoking. NICE was also aware of the reports produced by other national organisations as well as Public Health England. NICE agreed during post-committee discussions with Public Health England that the guideline should reflect the guidance produced by others when advising people who want to stop smoking about e-cigarettes.

How the recommendations might affect practice

Many staff are not aware of what advice to give on e‑cigarettes so staff will need information and training. Managers of services providing stop smoking support may need to ensure staff are aware of the latest information, but the costs should be minimal.

Full details of the evidence and the committee's discussion are in evidence review C.

If a person who smokes wants to quit

The discussion below explains how the committee made recommendations 1.6.1 to 1.6.6.

Why the committee updated the recommendations

People who want to stop smoking should be referred to stop smoking support in their area because evidence and expert opinion showed that support provided by these services is clinically effective and highly cost effective in helping people to stop smoking. Managers should ensure that staff are available in primary or community settings to offer pharmacotherapy and very brief advice if there are no local stop smoking services or the person does not want to be referred.

Many people try to quit smoking using a variety of methods. Topic experts believe that allowing a person to choose the method that they prefer, provided it is not a pharmacotherapy that is unsuitable for them, is likely to increase success. But the committee recommended that before agreeing the approach to take with the smoker, stop smoking services, GPs and other prescribers should explain that a combination of pharmacotherapy and behavioural support may be the best option.

How the recommendations might affect practice

Most organisations will not need to change practice and the recommendations will support best practice.

Full details of the evidence and the committee's discussion are in evidence review E.

If a person who smokes is not ready to quit

The discussion below explains how the committee made recommendation 1.7.1.

Why the committee updated the recommendations

The committee noted that changing smoking behaviour might not be a priority for some people because of other more pressing personal needs and goals. Unlike people who are motivated to change, people who are not motivated to stop smoking may need more information about the benefits of quitting. Using each contact to find out if they are ready to take up the offer for support could make it more likely that they will quit smoking.

How the recommendations might affect practice

Asking about smoking status and giving advice should be part of routine care. The recommendations will reinforce current best practice and organisations should not need to change practice.

Full details of the evidence and the committee's discussion are in evidence review E.

Recommendations that have not been updated

Evidence for recommendations from the previous guideline that have not been updated (sections 1.8 to 1.12) can be found on the evidence tab for this guideline.

  • Public Health England
  • National Institute for Health and Care Excellence (NICE)