Shared learning database

Birmingham Community Healthcare
Published date:
January 2013

NICE Guidance TA 123 - Varenicline July 2007 - Designing a pathway for a multi-disciplinary team to implement NICE guidance.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To ensure the availability of Varenicline according to NICE guidance whilst the model of care for stop smoking services was a multidisciplinary team, many of whose members would not have the registration or the competency to assess referred smokers appropriate for Varenicline or to monitor the smoker for effects of taking Varenicline. No member of the team was registered to prescribe Varenicline.

An important driver was the evidence based effectiveness of Varenicline with its minimal side effect profile. Two week and 52 week cessation rates are approximately for nicotine replacement therapy are 30% and 15% whilst rates for Varenicline are 47% and 23%. The partial agonist mechanism of Varenicline means that the enjoyment effects of smoking whilst taking Varenicline are partially blocked. This means that Varenicline, in addition to being marginally more effective, offered both an alternative to existing smoking cessation therapies and a novel approach. This is important because many people referred to the service had attempted smoking cessation several times previously.

Reasons for implementing your project

NICE guidance TA 123 - Varenicline was published in July 2007. The guidance recommended that Varenicline is an option for smokers who have expressed a desire to quit smoking. In addition Varenicline should normally be prescribed only as part of a programme of behavioural support. NICE technological appraisal recommendations are legally required to be implemented. BCHC Stop Smoking Service intended to add Varenicline to the first line range of smoking cessation treatments the service provided by the trust. However, BCHC faced the challenge of overcoming the following constraints:

BCHC Stop Smoking Service (SSS) is provided by both professionally registered and non-professionally registered providers.

Whilst professionally registered providers may be able to assess clients who wish to stop smoking using Varenicline, non-professionally registered providers are not.

Professionally registered providers and non-professionally registered providers cannot supply Varenicline as it is a prescription only medicine (POM).

Clients attending a BCHC stop smoking session may express a wish to either use Varenicline or be given information relating to this drug. The client may have self-referred or been referred by a GP or other healthcare worker. The client may be unaware that some service providers are not qualified to provide assessment for Varenicline.

This situation created three dilemmas for the Stop Smoking Service. Firstly how to maintain the principal that the service would continue to offer all types of smoking cessation therapy that was recommended by NICE that meant including Varenicline in the Stop Smoking Service options. Secondly how to maintain the principal that people seeking help with smoking cessation may be counselled by either professionally registered providers or by their non professionally registered colleagues. Thirdly how to maintain delivery the expectation to people attending the service that a full range of smoking cessation care is provided by Stop Smoking Service. It is counter-productive to turn people seeking help away because of a limited service.

For extended context please see the supporting material.

How did you implement the project

The senior team of the Stop Smoking Service met with Head Medicines Management to develop a pathway in which Varenicline was offered as an option by the service, as an equal first line therapy to Nicotine Replacement Therapy and other options.

The development included consultation with general practitioner colleagues. Firstly, general practitioners agreed to prescribe Varenicline only when a person seeking smoking cessation was engaged and was being helped by the Stop Smoking Service. Thus the first step at the general practitioners would be the signposting of a person seeking smoking cessation (with or without Varenicline) to the Stop Smoking Service.

Secondly the Stop Smoking Service with Medicines Management developed a comprehensive pathway for both professionally registered and non-professionally registered providers appropriate for each provider's competency. In the instant of a professionally registered provider an assessment of suitability, request to the general practitioner for a prescription subject to general practitioner assessment agreement, and the monitoring of effectiveness and side effects of Varenicline.

For the non-professionally registered provider the pathway was appropriately cautious: the provider collaborating closely with general practitioner colleagues so that the latter assessed the safety of Varenicline before providing a prescription, and monitored the person for side effects over the prescription period (prompted by two weekly communication letters from the Stop Smoking Service).

In effect, general practitioners referred into the Stop Smoking Service for all people seeking smoking cessation and received a high level of communication information from the Stop Smoking Service to ensure people's safety. The general practitioners' patients received a intense input from the Stop Smoking Service to maximise support whilst attempting to cease smoking.

The full details are described in the pathway document, an appendix to this entry in the supporting material.

The Stop Smoking Service believes that this revolutionary approach was only achieved with the very detailed input and support of the Medicines Management team.

Key findings

Please refer to the appendix of Tables 1-5 in the supporting material. Table 1 shows that the proportion of prescriptions for nicotine replacement therapy and varenicline was consistent across the years 2011-2013. Table 2 and 3 show the proportion of the population of Birmingham who smoke is average for white British population and lower for population who belong to other ethnic groups. (Reference NICE TA 123 costing template).

In 2008 The availability of all first line smoking cessation products resulted in 50% of all smoking cessation consultations being for varenicline. In 2012 the proportion had increased to 60%. (Personal information stop smoking lead). However the outcome of the consultations is that approximately 80% people chose to use nicotine replacement therapy and 20% varenicline. The uptake of all smoking cessation treatments was approximately three times for white British population with respect to other Birmingham ethnic groups, approximately 5% compared to 1.5% (table 3).

In spite of the higher uptake of nicotine replacement therapy, varenicline treatment is more effective for out users: 50% success at 4 weeks post treatment for nicotine replacement therapy compared to 60% success at 4 weeks post treatment for Varenicline.

There have been no adverse incidents reported over 4 years.

The development of the Varenicline pathway by Birmingham Community Healthcare's Stop Smoking Service demonstrates how NICE guidance can be used to develop a revolutionary pathway that optimises the availability of an evidence based medicine to users of our health service.

The NICE guidance recommendations were the driver that the guidance should be implemented, and the driver of the shape of that implementation. (In particular, in this case, that a Stop Smoking Service should offer all forms of smoking cessation technology as equal first line interventions.)

The technology, the manufacturers submission and the consideration of the evidence provided an evidence based foundation on which the pathway was constructed.

Key learning points

1) Development of a treatment pathway is an effective way of implementing the detail and the scope of a NICE guidance technological assessment.
2) The use of a detailed pathway enabled implementation of a NICE technological assessment with a multi-disciplinary team, without causing inconvenience to the people seeking the service.
3) The development of the pathway required multi-disciplinary collaboration outside the team that the guidance applied to. The collaboration was described and detailed and supportive. The collaboration was essential for the success of the pathway.
4) The submission of this pathway to the NICE shared learning database has highlighted the variation in uptake between the different ethnic groups in Birmingham. The smoking cessation team in 2013-4 intends to increase the uptake from each of the different ethnic groups.

Contact details

Carol Carter
Clinical Lead Nurse
Birmingham Community Healthcare

Primary care
Is the example industry-sponsored in any way?