Appendix A: recommendations for policy and practice and supporting evidence statements

This appendix sets out the recommendations and the associated evidence statements taken from the review of effectiveness (see appendix D for the key to study types and quality assessments)

Recommendations are followed by the evidence statement(s) that underpin them. The numbering of the evidence statements reflects the numbering that was used in the brief interventions review. For example, (evidence statement 1) below is numbered 1 in the brief interventions review. Where a recommendation is not directly taken from the evidence statements, but is inferred from the evidence, this is indicated by IDE (inference derived from the evidence).

The review is available on the NICE website.

Who should receive advice?

Recommendation 1

Everyone who smokes should be advised to quit, unless there are exceptional circumstances[18]. People who are not ready to quit should be asked to consider the possibility and encouraged to seek help in the future. If an individual who smokes presents with a smoking-related disease, the cessation advice may be linked to their medical condition.

(IDE)

Recommendation 2

People who smoke should be asked how interested they are in quitting. Advice to stop smoking should be sensitive to the individual's preferences, needs and circumstances: there is no evidence that the 'stages of change' model[19] is more effective than any other approach.

(Evidence statement 10 and IDE)

Who should advise smokers and how?

Recommendation 3

GPs should take the opportunity to advise all patients[18] who smoke to quit when they attend a consultation. Those who want to stop should be offered a referral to an intensive support service (for example, NHS Stop Smoking Services). If they are unwilling or unable to accept this referral they should be offered pharmacotherapy, in line with NICE technology appraisal guidance no. 39[20], and additional support. The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year, where possible.

(Evidence statements 1 and 7)

Recommendation 4

Nurses in primary and community care should advise everyone who smokesto stop and refer them to an intensive support service (for example, NHS Stop Smoking Services). If they are unwilling or unable to accept this referral they should be offered pharmacotherapy, in line with NICE technology appraisal guidance no. 39 and additional support. Nurses who are trained NHS stop smoking counsellors may 'refer' to themselves where appropriate. The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year, where possible.

(Evidence statements 2 and 7)

Recommendation 5

All other health professionals, such as hospital clinicians, pharmacists and dentists, should refer people who smoke[18][20] to an intensive support service (for example, NHS Stop Smoking Services). If the individual is unwilling or unable to accept this referral, practitioners with suitable training should offer a prescription of pharmacotherapy, in line with NICE technology appraisal guidance no. 39[20], and additional support. Those who are trained NHS stop smoking counsellors may 'refer' to themselves. The smoking status of those who are not ready to stop should be recorded in clinical records and reviewed with the individual once a year, where possible.

(Evidence statements 1, 2, 7 and 27 and IDE)

Recommendation 6

Community workers[21] should refer people who smoke to an intensive support service (for example, NHS Stop Smoking Services). Those who are trained NHS stop smoking counsellors may 'refer' to themselves.

(Evidence statement 27, IDE)

Strategic recommendations for policy makers, commissioners and managers

Recommendation 7

Strategic health authorities, NHS hospital trusts, PCTs, community pharmacies, local authorities and local community groups should review smoking cessation policies and practices to take account of the recommendations in this guidance.

(IDE)

Recommendation 8

Smoking cessation advice and support should be available in community, primary and secondary care settings for everyone who smokes. Local policy makers and commissioners should target hard to reach and deprived communities including minority ethnic groups, paying particular attention to their needs.

(IDE)

Recommendation 9

Monitoring systems should be set up to ensure health professionals have access to information on the current smoking status of their patients. This should include information on: a) the most recent occasion on which advice to stop was given, b) the nature of advice offered and c) the response to that advice.

(IDE)

Evidence statements

Evidence statement 1

A body of level 1+ evidence directly applicable to UK health care settings supports the efficacy of physician advice as a brief intervention for smoking cessation.

Evidence statement 2

A body of level 1+ evidence directly applicable to the UK supports the efficacy of nurse structured advice as a brief intervention for smoking cessation in primary care and community settings. However, the primary focus of the contact in these studies was smoking, so these interventions are not brief opportunistic interventions made during routine care. In addition, poor uptake of invitations to contact nurses for assistance with smoking cessation was noted in some UK studies. There is insufficient evidence to say whether opportunistic advice increases quit rates. A moderately sized body of evidence failed to detect any effect of advice and interventions delivered by nurses as part of a health check.

Evidence statement 7

A body of level 1+ evidence directly applicable to the UK supports the efficacy of nicotine replacement therapy (NRT) as part of a brief intervention for smokers wishing to make a quit attempt.

Evidence statement 10

A moderately sized body of evidence has not found a benefit of stage-matched over unmatched brief interventions. A moderately sized body of evidence has yielded conflicting results on the efficacy of stage-matched interventions compared with no intervention.

Evidence statement 27

There is insufficient evidence from direct comparisons to draw firm conclusions about the influence of the profession of a provider delivering a brief smoking cessation intervention, or the influence of features of the profession, on intervention effectiveness.

Cost-effectiveness evidence

Overall, brief interventions were found to be cost effective, and would support the above recommendations.

The cost-effectiveness analysis demonstrated that brief interventions conducted by GPs and nurses, in all settings, to all age groups included in the model, and with all adjuncts (NRT, self-help, telephone helpline) can generate quality-adjusted life year (QALY) gains at a low cost. The cost per QALY tends to increase as the patient's age increases, but brief interventions delivered to a 60 year old cohort are still cost effective.

When only comparing the costs of an intervention with no intervention, the estimated incremental cost per QALY gained varied from around £221 to around £9515, depending on the assumptions used (see appendix E – the economic analysis modelling report – for further details).

When the healthcare savings are included (as smokers quit smoking and avoid preventable disease), these are offset by the cost of the intervention. Using this method, the incremental costs per QALY gained vary from £135 to £6472, depending on the assumptions used.

These variations reflect the results from the sensitivity analysis (regarding the assumptions made on background quit rates, length of intervention, age of the individual and their level of dependency).



[18] Occasionally it might be inappropriate to advise a patient to quit; for example because of their presenting condition or personal circumstances.

[19] DiClemente CC, Prochaska J. et al. (1991) The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology. Vol 59(2) 295-304.

[20] Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation. NICE technology appraisal no. 39 (2002). [Replaced by NICE public health guidance 10]

[21] Community workers are practitioners working outside the health sector who have a remit for smoking cessation.