NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

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1 Evidence-based stop smoking services and quitlines bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: Pathway last updated: 21 April 2016 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved

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3 1 Recommendations for specialist stop smoking services and quitlines No additional information 2 Standards for and provision of evidence-based stop smoking services Organisation of publicly funded services Determine the characteristics of the local population of people who smoke or use other forms of tobacco. Determine the prevalence of all forms of tobacco use locally. Ensure evidence-based stop smoking services target minority ethnic and socioeconomically disadvantaged communities in the local population. Ensure evidence-based stop smoking services provide a good service by maintaining adequate staffing levels, including a full-time coordinator (or the equivalent). Set realistic performance targets for both the number of people using the service and the proportion who successfully quit smoking. These targets should reflect the demographics of the local population. Services should: aim to treat at least 5% of the estimated local population of people who smoke or use tobacco in any form each year aim for a success rate of at least 35% at 4 weeks, validated by carbon monoxide monitoring. This figure should be based on all those who start treatment, with success defined as not having smoked in the third and fourth week after the quit date. Success should be validated by a CO monitor reading of less than 10 ppm at the 4-week point. This does not imply that treatment should stop at 4 weeks. Audit performance data routinely and independently and make the results publicly available. Audits should also be carried out on exceptional results 4-week quit rates lower than 35% or above 70% to determine the reasons for unusual performance, and to help identify best practice and ensure it is being followed. Establish links between contraceptive services, fertility clinics and ante- and postnatal services. These links should ensure health professionals use the many opportunities available to them (at various stages of the woman's life) to offer smoking advice or referral to a specialist service, where appropriate. Page 3 of 19

4 Interventions offered by stop smoking services Offer behavioural counselling, group behaviour therapy, pharmacotherapies or a combination of treatments that have been proven to be effective. Ensure clients receive behavioural support from a person who has had training and supervision that complies with the Standard for training in smoking cessation treatments or its updates. Provide tailored advice, counselling and support, particularly to clients from minority ethnic and disadvantaged groups. Provide services in the language chosen by clients, wherever possible. Ensure the local evidence-based stop smoking service aims to treat minority ethnic and disadvantaged groups at least in proportion to their representation in the local population of tobacco users. See also recommendations on advice on quit smoking drugs for people who want to stop smoking in this pathway. Telephone quitline services Ensure publicly sponsored telephone quitlines offer a rapid, positive and authoritative response. Where possible, callers whose first language is not English should have access to information and support in their chosen language. All staff should receive smoking cessation training (at least in brief interventions to help people stop smoking). Staff who offer counselling should be trained to at least level two (individual behavioural counselling) and preferably, they should hold an appropriate counselling qualification. Training should comply with the standard for training in smoking cessation treatments or its updates. Quality standards The following quality statements are relevant to this part of the pathway. Smoking cessation quality standard 3. Behavioural support with pharmacotherapy 4. Pharmacotherapy Page 4 of 19

5 5. Outcome measurement 3 Smoking cessation services provided for primary, community and acute health services No additional information 4 Services for hospitals Commissioners of public health services should ensure that evidence-based stop smoking services can provide cessation support to hospitals. This should include a fast-track referral system after discharge for patients who have tried to quit smoking in hospital. Commissioners of public health services should develop a clear referral plan with links between primary and acute trusts. 5 Services for pregnant women and their partners No additional information 6 Helping partners of pregnant women, and others in the household, to stop smoking Context Interventions which are effective with the general population will not necessarily work with the partners of women who are pregnant. For example, simply providing booklets, self-help guidance or media education campaigns is not effective with this group around the time of pregnancy. What action should be taken? Provide clear advice about the danger that other people's tobacco smoke poses to the pregnant woman and to the baby before and after birth. Recommend not smoking around the pregnant woman, mother or baby. This includes not smoking in the house or car. Page 5 of 19

6 Offer partners who smoke help to stop using a multi-component intervention that comprises three or more elements and multiple contacts. Discuss with them which options to use and in which order, taking into account: their preferences contra-indications and the potential for adverse effects from pharmacotherapies such as NRT the likelihood that they will follow the course of treatment their previous experience of smoking cessation aids. Do not favour one medication over another. Together, choose the one that seems most likely to succeed taking into account the above. See also recommendations about quit smoking drugs in this pathway. 7 Helping women who are disadvantaged to stop smoking Ensure services are delivered in an impartial, client-centred manner. They should be sensitive to the difficult circumstances many women who smoke find themselves in. They should also take into account other sociodemographic factors such as age and ethnicity and ensure provision is culturally relevant. This includes making it clear how women who are non-english speakers can access and use interpreting services. Involve these women in the planning and development of services. Ensure services are flexible and coordinated. They should take place in locations and at times that make them easily accessible and should be tailored to meet individual needs. Collaborate with the family nurse partnership pilot and other outreach schemes to identify additional opportunities for providing intensive and ongoing support. (Note: family nurses make frequent home visits.) Work in partnership with agencies that support women who have complex social and emotional needs. This includes substance misuse services, youth and teenage pregnancy support and mental health services. See also recommendations about helping all adults who are disadvantaged in this pathway. Page 6 of 19

7 8 Initial and ongoing support for pregnant women Context Studies have shown that the following interventions are effective in helping women who are pregnant to quit smoking: cognitive behaviour therapy motivational interviewing structured self-help and support from evidence-based stop smoking services. In addition, in other countries the provision of incentives to quit has been shown to be effective with this group (research is required to see whether it would work in the UK). Interventions using a 'stages of change' approach have had mixed success. (In some studies the approach was effective, in others it was no better than the control.) Giving pregnant women feedback on the effects of smoking on the unborn child and on their own health (such as reports of urinary cotinine levels) is not effective. What action should be taken? During the first face-to-face meeting, discuss how many cigarettes the woman smokes and how frequently. Ask if anyone else in the household smokes (this includes her partner if she has one). Provide information about the risks of smoking to an unborn child and the benefits of stopping for both mother and baby. Address any concerns she and her partner or family may have about stopping smoking and offer personalised information, advice and support on how to stop 1. If partners or other family members are present at the first face-to-face meeting, encourage those who smoke to quit. If they smoke but are not at the meeting, ask the pregnant woman to suggest they contact evidence-based stop smoking services and provide her with contact details (for example, telephone and address card). Provide the woman with intensive and ongoing support (brief interventions alone are unlikely to be sufficient) throughout pregnancy and beyond. This includes regularly monitoring her smoking status using CO tests. The latter may encourage her to try to quit and can also be a useful way of providing positive feedback once a quit attempt has been made. Page 7 of 19

8 1 The British National Formulary (2010) advises on use of NRT during pregnancy: 'intermittent therapy is preferable but avoid liquorice flavoured nicotine products'. Page 8 of 19

9 Biochemically validate that the woman has quit on the date she set and 4 weeks after. Where possible, use urine or saliva cotinine tests, as these are more accurate than CO tests and can detect exposure over the past few days rather than hours. When carrying out these tests, check whether the woman is using nicotine replacement therapy (NRT) as this may raise her cotinine levels. Note: no measure can be 100% accurate. Some people may smoke so infrequently or inhale so little that their intakes cannot reliably be distinguished from that due to passive smoking. If the woman says that she has stopped smoking, but the CO test reading is higher than 10 ppm, advise her about possible CO poisoning and ask her to call the free Health and Safety Executive gas safety advice line on: However, it is more likely that she is still smoking and any further questions must be phrased sensitively to encourage a frank discussion. If she stopped smoking in the 2 weeks prior to her maternity booking appointment, continue to provide support, in line with the recommendations above and evidence-based stop smoking services practice protocols. Record the method used to quit smoking, including whether or not she received help and support. Follow up 12 months after the date she set to quit. Establish links with contraceptive services, fertility clinics and ante- and postnatal services so that everyone working in those organisations knows about local evidence-based stop smoking services. Ensure they understand what these services offer and how to refer people to them. Use of NRT and other pharmacological support Context There is mixed evidence on the effectiveness of NRT in helping women to stop smoking during pregnancy. The most robust trial to date has found no evidence that it is effective (or that it affects the child's birthweight). In addition, there are insufficient data to form a judgement about whether or not NRT has any impact on the likelihood that a child will need special care or will be stillborn. What action should be taken? Discuss the risks and benefits of NRT with pregnant women who smoke, particularly those who do not wish to accept other help from evidence-based stop smoking services. Use only if Page 9 of 19

10 smoking cessation without NRT fails. If they express a clear wish to receive NRT, use professional judgement when deciding whether to offer a prescription. Only prescribe NRT for use once they have stopped smoking (they may set a particular date for this). Only prescribe 2 weeks of NRT for use from the day they agreed to stop. Only give subsequent prescriptions to women who have demonstrated, on re-assessment, that they are still not smoking. Advise pregnant women who are using nicotine patches to remove them before going to bed. Neither varenicline or bupropion should be offered to pregnant or breastfeeding women. Quality standards The following quality statements are relevant to this part of the pathway. Smoking cessation quality standard 3. Behavioural support with pharmacotherapy 4. Pharmacotherapy 5. Outcome measurement Antenatal care quality standard 5. Risk assessment smoking cessation 9 Contacting pregnant women who have been referred for help to stop smoking Telephone all women who have been referred for help. Discuss smoking and pregnancy and the issues they face, using an impartial, client-centred approach. Invite them to use the service. If necessary (and resources permitting), ring them twice and follow-up with a letter. Advise the maternity booking midwife of the outcome. Attempt to see those who cannot be contacted by telephone. This could happen during a routine antenatal care visit (for example, when they attend for a scan). Page 10 of 19

11 Address any factors which prevent the women from using smoking cessation services. This could include a lack of confidence in their ability to quit, lack of knowledge about the services on offer, difficulty accessing them or lack of suitable childcare. It could also include a fear of failure and concerns about being stigmatised. If women are reluctant to attend the clinic, consider providing structured self-help materials or support via the telephone helpline. Also consider offering to visit them at home, or at another venue, if it is difficult for them to attend specialist services. Send information on smoking and pregnancy to those who opt out during the initial telephone call. This should include details on how to get help to quit at a later date. Such information should be easily accessible and available in a variety of formats. For further information see smoking cessation in maternity services in this pathway. Quality standards The following quality statement is relevant to this part of the pathway. Smoking cessation quality standard 3. Behavioural support with pharmacotherapy 10 Providing workplaces with support to help people quit smoking Providing services Offer one or more interventions that have been proven to be effective. 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. Prioritising resources Offer support to employers who want to help their employees to stop smoking. Where appropriate and feasible, provide support on the employer's premises. Page 11 of 19

12 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. See also recommendations for employers and employees in this pathway. Quality standards The following quality statement is relevant to this part of the pathway. Smoking: reducing tobacco use quality standard 4. Workplace policy Page 12 of 19

13 Glossary Brief interventions Brief interventions (also known as brief advice) to help people stop smoking involve opportunistic advice, discussion, negotiation or encouragement and, where necessary, referral to more intensive treatment. They are delivered by a range of professionals, typically in less than 10 minutes. The package provided depends on a number of factors including someone'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 person's commitment to quit pharmacotherapy and/or behavioural support self-help material referral to more intensive support such as evidence-based stop smoking services. Cardiovascular disease Cardiovascular disease (CVD) is generally due to reduced blood flow to the heart, brain or body caused by atheroma or thrombosis. Plaques (plates) of fatty atheroma build up in different arteries during adult life. These can eventually cause narrowing of the arteries, or trigger a local thrombosis (blood clot) which completely blocks the blood flow. The main types of CVD are: coronary heart disease (CHD), stroke and peripheral arterial disease (PVD). Source: What is cardiovascular disease? What is coronary heart disease? What is stroke? Disadvantaged adults Adults who are disadvantaged include (but are not limited to): those on a low income (or who are members of a low-income family) those on benefits those living in public or social housing some members of black and minority ethnic groups those with a mental health problem Page 13 of 19

14 those with a learning disability those who are institutionalised (including those serving a custodial sentence) those who are homeless. Disadvantaged areas Local agencies define disadvantaged areas in a variety of ways. An example is the 'Index of Multiple Deprivation 2007'. This combines indicators on economic, social and housing issues to produce a single deprivation score. Evidence-based stop smoking services Local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. The professionals involved may include midwives who have been specially trained to help pregnant women who smoke to quit. Group behaviour therapy Group behaviour therapy programmes involve weekly meetings for the first 4 weeks of a quit attempt. During these meetings, 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. See 'Individual behavioural counselling for smoking cessation'. Individual behavioural counselling This is a face-to-face encounter between someone who smokes and a counsellor trained in smoking cessation. Mass-media campaigns Mass-media interventions use a range of methods to communicate a message. This can include local, regional or national television, radio and newspapers, and leaflets and booklets. It can also include new media. In this pathway, 'new media' refers to communication via the Internet or mobile phone. On the Internet, it can involve anything from real-time streaming of information and podcasts, to discussions with experts and the use of social networking sites. (An example of real-time Page 14 of 19

15 streaming of information is the 'breaking news' text that appears along the bottom of the screen during some TV news programmes.) The aim of mass-media interventions is to reach large numbers of people without being reliant on face-to-face contact. Pharmacotherapies Stop smoking advisers and healthcare professionals may recommend and prescribe nicotine replacement therapy (NRT), varenicline 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, varenicline or bupropion. Point-of-sales Point-of-sales interventions take place at the point where tobacco could be sold. Primarily, they aim to deter shopkeepers from making illegal sales. Schools In this pathway 'Schools' is used to refer to the following educational establishments: maintained and independent primary, secondary and special schools city technology colleges and academies pupil referral units, secure training and local authority secure units further education colleges 'extended schools' where childcare or informal education is provided outside school hours. Self-help materials 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. See Self-help interventions for smoking cessation. Page 15 of 19

16 Telephone counselling and quitlines 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. CI Confidence interval. There is always some uncertainty in research. This is because a small group of people is studied to predict the effects of an intervention on the wider population. The confidence interval is a way of expressing how certain we are about the findings from a study, using statistics. It gives a range of results that is likely to include the 'true' value for the population. The CI is usually stated as '95% CI', which means that the range of values has a 95 in a 100 chance of including the 'true' value. For example, a study may state that 'based on our sample findings, we are 95% certain that the 'true' population blood pressure is not higher than 150 and not lower than 110'. In such a case the 95% CI would be 110 to 150. A wide confidence interval indicates a lack of certainty about the true effect of the test or treatment often because a small group of patients has been studied. A narrow confidence interval indicates a more precise estimate (for example, if a large number of patients have been studied). ES Effect size. A measure that shows the magnitude of the outcome in one group compared with that in a control group. For example, if the absolute risk reduction is shown to be 5% and it is the outcome of interest, the effect size is 5%. The effect size is usually tested, using statistics, to find out how likely it is that the effect is a result of the treatment and has not just happened by chance (that is, to see if it is statistically significant). i NICE analysts have calculated this figure using data from the original study. Page 16 of 19

17 ICER Incremental cost effectiveness ratio. A measure of the cost effectiveness of a treatment or health intervention. It estimates how much more the benefits of a certain treatment cost, compared with other treatments or health interventions. NNT Number needed to treat. The average number of people who need to receive an intervention to get a positive outcome. For example, if the NNT is four, then 4 people would have to receive the intervention to ensure one of them gets better. The closer the NNT is to one, the better the intervention. However, as with most data, caution is needed when considering whether results apply to populations beyond the sample described in the original study. OR Odds ratio. Odds are a way to represent how likely it is that something will happen (the probability). An odds ratio compares the probability of something in one group with the probability of the same thing in another. An odds ratio of 1 between two groups would show that the probability of the event (for example a person developing a disease, or an intervention working) is the same for both. Sometimes probability can be compared across more than two groups in this case, one of the groups is chosen as the 'reference category', and the odds ratio is calculated for each group compared with the reference category. For example, to compare the risk of dying from lung cancer for non-smokers, occasional smokers and regular smokers, non-smokers could be used as the reference category. Odds ratios would be worked out for occasional smokers compared with non-smokers and for regular smokers compared with non-smokers. QALY Quality-adjusted life year. A measure of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life. One QALY is equal to 1 year of life in perfect health. QALYS are calculated by estimating the years of life remaining for a person following a particular treatment or intervention and weighting each year with a quality of life score (on a Page 17 of 19

18 zero to one scale). It is often measured in terms of the person's ability to perform the activities of daily life, freedom from pain and mental disturbance. RCT Randomised controlled trial. A study in which a number of similar people are randomly assigned to two (or more) groups to test a specific drug or intervention. One group (the experimental group) receives the intervention being tested, the other (the comparison or control group) receives an alternative intervention, a dummy intervention (placebo) or no intervention at all. The groups are followed up to see how effective the experimental intervention was. Outcomes are measured at specific times and any difference in response between the groups is assessed statistically. This method is also used to reduce bias. SD Standard deviation. A measure used to summarise numerical data and describe how 'spread out' a set of measures (or 'values') are from the average. For example, the average height of a group of schoolchildren can be calculated using the total of all their heights added together and then divided by the number of schoolchildren in the group. Standard deviation measures the 'spread' of those heights. So, in the example it tells you whether all those in the group were about the same height or whether some were very tall and some were short. Sources Smoking: stopping in pregnancy and after childbirth (2010) NICE guideline PH26 Stop smoking services (2008) NICE guideline PH10 Smoking: workplace interventions (2007) NICE guideline PH5 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of Page 18 of 19

19 opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT nice@nice.org.uk Page 19 of 19