Appendix A: recommendations for policy and practice and supporting evidence statements
This appendix sets out the recommendations and the associated evidence statements taken from a review of effectiveness, a review of the economic literature and an economic model (see appendix D for the key to study types and quality assessments). It also includes details of a survey of current practice.
Recommendations are followed by the evidence statement(s) underpinning them. For example: [evidence statement number 1] indicates that the linked statement is numbered 1 in the review 'Summary of evidence of effectiveness of smoking cessation interventions in the workplace'. 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 following smoking cessation interventions, as defined below, have been proven to be effective.
Brief interventions for smoking cessation involve opportunistic advice, discussion, negotiation or encouragement and are delivered by a range of primary and community care professionals, typically within 5–10 minutes. The package provided depends on a number of factors including the individual's willingness to quit, how acceptable they find the intervention and previous methods they have used. It may include one or more of the following:
simple opportunistic advice
an assessment of the individual's commitment to quit
pharmacotherapy and/or behavioural support
referral to more intensive support such as the NHS Stop Smoking Services.
Group behaviour therapy programmes involve scheduled meetings where people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy) delivered over at least two sessions.
(NICE 2006b; NICE 2006c; Stead and Lancaster 2005)
Stop smoking advisers and healthcare professionals may recommend and prescribe nicotine replacement therapy (NRT) or bupropion as an aid to help people to quit smoking, along with giving advice, encouragement and support. Before prescribing a treatment, they take into account the person's intention and motivation to quit and how likely it is they will follow the course of treatment. They also consider which treatments the individual prefers, whether they have attempted to stop before (and how), and if there are medical reasons why they should not be prescribed NRT or bupropion.
(NICE 2002; NICE 2006b)
Self-help materials comprise any manual or structured programme, in written or electronic format, that can be used by individuals in a quit attempt without the help of health professionals, counsellors or group support. Materials can be aimed at anyone who smokes, particular populations (for example, certain age or ethnic groups) or may be interactively tailored to individual need. (Lancaster and Stead 2005b; NICE 2006b)
Telephone counselling and quitlines provide proactive or reactive advice, encouragement and support over the telephone to anyone who smokes who wants to quit, or who has recently quit.
(Stead et al 2006; NICE 2006b; NICE 2006c)
Publicise the interventions identified in this guidance and make information on local stop smoking support services widely available at work. This information should include details on the type of help available, when and where, and how to access the services.
Be responsive to individual needs and preferences. Where feasible, and where there is sufficient demand, provide on-site stop smoking support.
Allow staff to attend smoking cessation services during working hours without loss of pay.
Develop a smoking cessation policy in collaboration with staff and their representatives as one element of an overall smokefree workplace policy.
(Evidence statements 1, 2, 5, 6, 7, 8, 10, 11, 12, 13, 15, IDE)
Contact local smoking cessation services, such as the NHS Stop Smoking Services, for information, advice and support.
Encourage employers to provide advice, guidance and support to help employees who want to stop smoking.
All those offering smoking cessation services including the NHS, independent or commercial organisations and employers.
Offer one or more interventions that have been proven to be effective (see above).
Ensure smoking cessation support and treatment is delivered only by staff who have received training that complies with the 'Standard for training in smoking cessation treatments'.
Ensure smoking cessation support and treatment is tailored to the employee's needs and preferences, taking into account their circumstances and offering locations and schedules to suit them.
(Evidence statements 1, 2, 5, 6, 7, 8, 11, 13)
Offer support to employers who want to help their employees to stop smoking. Where appropriate and feasible, provide support on the employer's premises.
If initial demand exceeds the resources available, focus on the following:
small and medium-sized enterprises (SMEs)
enterprises where a high proportion of employees are on low pay
enterprises where a high proportion of employees are from a disadvantaged background
enterprises where a high proportion of employees are heavy smokers.
(Evidence statements 1, 2, 16)
Although there are no available studies exploring which workplace interventions are most effective in the context of smokefree legislation, one
2 (+) study of a variety of workplace intervention types, offered in the context of a localised smoking ban found that more intensive interventions (for example, group treatment and 1-hour clinics) produce higher success rates than less intensive interventions (for example, brief individual counselling and self-help manuals). It is unclear how readily these findings translate to workplaces in jurisdictions where comprehensive smokefree legislation has been introduced.
A 1 (++) systematic review and a 1 (+) meta-analysis of the available international literature indicates that the most effective smoking cessation interventions in workplace settings are those interventions that have proven effectiveness more broadly. There is strong evidence that group therapy, individual counselling and pharmacological treatments all have an effect in facilitating smoking cessation. However, both reviews failed to identify effects due to particular intervention type. There is also evidence that minimal interventions, including brief advice from a health professional, are effective. Self-help manuals appear to be less effective, although there is limited evidence that interventions tailored to the individual have some effect.
A 1 (+) study and a 2 (++) study found that men and women were equally successful in achieving abstinence in workplace smoking cessation programmes; however, important gender differences were apparent in smoking attitudes and behaviours. Women had less confidence in their ability to quit and required extra stimuli in order to quit smoking. Although these findings are based on American studies, they are likely to be broadly applicable to a UK setting.
Although no studies were identified in the literature search that specifically address effective workplace interventions for younger and older smokers, evidence from a 2 (++) study indicates that older smokers are more likely to achieve successful abstinence in workplace interventions than younger smokers (although these employees were also more likely to be managers and light smokers). Furthermore, two 2 (+) studies examined the impact of age and job stress on cessation. Results from one study revealed that younger employees benefited more from higher demands than older employees with regards to smoking cessation. However, these findings were not supported in the other 2 (+) study. Therefore, although further research is needed in this area, it may be possible that younger employees who smoke require more intensive support for smoking cessation than older smokers, and that specifically tailoring interventions based on age may be beneficial. Although these findings are based on American studies, they are likely to be broadly applicable to a UK setting.
A 2 (+) study found that although there are ethnic differences in baseline smoking patterns and attitudes towards cessation, ethnicity was not a significant predictor of successful abstinence. Another 1 (+) study found that a tailored intervention which incorporated linguistically and culturally appropriate materials, was effective in promoting behaviour change in a working class multi-ethnic population. Although these studies are from the USA, which has a different ethnic composition to the UK, it is likely that their findings are broadly applicable to a UK setting.
No studies were identified in the literature search that specifically addressed effective workplace interventions for temporary or casual workers. As delivering workplace interventions to this population pose a significant challenge, research is urgently needed in this area.
Various 4 (+) sources have indicated that creating and enforcing a smoking compliance strategy is an effective way to increase compliance. Specific tips for enforcing smokefree policy include providing training on how to enforce the policy, establishing links between the policy and HR policies, increasing awareness of the consequences of breaching policy, providing reminders that it is a criminal offence not to comply with smokefree legislation and notifying staff that action will be taken if someone is in breach of the policy.
According to a 1 (++) systematic review, a key way that employers can encourage smokers to quit is by offering smoking cessation support. Such support is particularly important in the context of workplace smoking bans.
A 2 (+) study concludes that because different types of smokers appear to choose different strategies for cessation, making a variety of smoking cessation strategies available to employees may meet the needs of more employees and increase participation in workplace programmes.
Two 1 (++) systematic reviews of international studies indicate that financial incentives can support and encourage smokers to quit. While the addition of incentives does not appear to increase the quit rates of smoking cessation interventions in the workplace, there is evidence that such incentives do improve recruitment rates into worksite cessation programmes, which may lead to higher absolute numbers of successful quitters in the long term.
According to a 2 (+) study, the majority of employed smokers are not ready to quit smoking. Therefore, smoking cessation materials and programmes need to recognise that smokers are at different stages of change rather than tailoring their materials only to those smokers who are highly motivated to quit. The researchers argue that proactive interventions are required, including access to subsidised pharmacological cessation aids, monetary incentives for assessment of smoking risk, direct personalised feedback, media/social marketing campaigns, and changes in the social norms and physical environment in the workplace, in public places, and in the home. Although this is an American study, its findings are likely to be broadly applicable to a UK setting.
Two 2 (++) studies indicate that a key factor predicting whether a workplace will offer smoking cessation support is the personal attitude of the employer towards employee health. So, a key way of encouraging employers to provide smoking cessation support may be to directly target leaders and persuade them of the benefits of investing in employee health and the role it plays in company success.
Two 2 (++) American studies, one 2 (-) Canadian study and one 2 (+) Scottish study provide strong evidence that small enterprises are far less likely to offer smoking cessation support than large enterprises. The findings of these studies suggest that small workplaces may have significant financial constraints that impede their ability to offer smoking cessation support and may also have characteristics that do not lend themselves to formal onsite programmes. Thus, unlike large enterprises, small enterprises have substantial needs in implementing smoking control activities in their worksite. As the conclusions of the US studies are echoed in a Scottish study, these findings are likely to be directly applicable to a UK setting.
Summary of findings from the experiences of smokefree Scotland and Ireland and a study of smoking cessation services in England
The Scottish and Irish experience of introducing smokefree legislation suggests that the demand for smoking cessation services will increase in the run-up to the smoking ban in England on 1 July. It also suggests that this demand will be linked to media activity.
Smoking cessation services are likely to face an increase in the number of employers wishing to use their services and an increase in demand direct from people who smoke. It is important to ensure resources are in place to meet the extra demand for smoking cessation services and treatments.
Overall, there is limited information on the cost effectiveness of workplace smoking cessation interventions, but the studies that were identified in the review suggest that they are cost effective.
The model aimed to estimate the cost effectiveness of smoking cessation interventions delivered in the workplace. These included:
brief advice plus self-help material
brief advice, self-help material and advice on using nicotine replacement therapy (NRT)
brief advice, self-help material, advice on using NRT and specialist support.
All interventions led to a reduction in the number of people who smoke, fewer comorbidities and more years of good health (QALYs) compared to 'no intervention'.
All interventions reduced the number of employees who smoke, leading to increased productivity compared to 'no intervention'. Cessation rates were directly linked to productivity: a high cessation rate led to lower associated productivity losses.
The net financial benefit for employers was calculated by subtracting the cost of the intervention from the productivity benefits. Most interventions begin to produce a net financial benefit after 2 years. Some of the cheaper interventions lead to a net financial benefit after 1 year.
Full details of the surveys of current practice and reviews of cost effectiveness and modelling can be found on the NICE website.