Smoking cessation guidelines for Scotland PREPARED BY ASH SCOTLAND AND HEBS

Transcription

1 Smoking cessation guidelines for Scotland PREPARED BY ASH SCOTLAND AND HEBS

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3 Smoking cessation guidelines for Scotland PREPARED BY ASH SCOTLAND AND HEBS

4 Acknowledgements Smoking cessation guidelines for Scotland ASH Scotland and HEBS Adapted by Susan Walker from: Raw, M., McNeill, A., West, R. (1998). Smoking Cessation Guidelines for Health Professionals. Thorax, 53 (Suppl 5): Part 1: S1-19 With permission from the BMJ Publishing Group Editorial team: Dr Ken Black, Senior Registrar in Public Health Medicine, HEBS Sally Haw, Research Specialist (Substance Misuse), HEBS Dr James Inglis, Consultant in Public Health Medicine, HEBS Maureen Moore, Chief Executive, ASH Scotland Health Education Board for Scotland and Action on Smoking and Health Scotland 2000 Published by the Health Education Board for Scotland Woodburn House, Canaan Lane, Edinburgh EH10 4SG Designed by One O Clock Gun Printed by Nimmos Colour Printers ISBN Prepared by ASH Scotland and HEBS ii

5 Purpose of these guidelines These guidelines are intended to give advice on how the National Health Service in Scotland and others can encourage and help people to stop smoking. They also aim to make the case for dedicating funds to smoking cessation services and for integrating smoking cessation into routine clinical care. The guidelines are intended for use by the primary care team, other health professionals, managers, commissioners of health services and others. They are based on published research and expert clinical experience. iii

6 About these guidelines These guidelines have been adapted from Smoking Cessation Guidelines for Health Professionals 1 (hereafter referred to as the HEA guidelines) published in the supplement to Thorax which laid down clinical guidelines on smoking cessation interventions for the NHS. Where appropriate, original text is reproduced, but the intention of this document is to set the guidance on smoking cessation within the context of the National Health Service in Scotland (NHSiS). Statistics, unless otherwise stated, are Scottish statistics. For further information on the scientific basis, review process and evidence base, please refer to Appendix One of this document and the original article as detailed above. Guidance on cost-effectiveness 2 was also published in the same Thorax supplement and is not repeated here as it is considered to be equally valid within the NHS in Scotland as for England and Wales. These guidelines for the NHSiS were commissioned by the Health Education Board for Scotland (HEBS) which is the national agency for health education in Scotland, and ASH Scotland, the leading voluntary organisation in Scotland campaigning for effective tobacco control policies. Professional endorsement At the time of going to press the following organisations have endorsed these guidelines: British Dental Association, British Lung Foundation, British Medical Association in Scotland, Cancer Awareness in Scotland, Cancer Research Campaign, Chest, Heart & Stroke Scotland, Community Practitioners and Health Visitors Association (Scotland), Macmillan Cancer Relief Scotland, National Asthma Campaign Scotland, The Roy Castle Lung Cancer Foundation, Royal College of General Practitioners in Scotland, Royal College of Midwives Scottish Board, Royal College Of Nursing Scotland, Royal College of Physicians Scotland, Royal College of Physicians and Surgeons of Glasgow, Royal iv

7 College of Surgeons of Edinburgh, Royal Pharmaceutical Society of Great Britain in Scotland, Scottish Affairs Committee of the Faculty of Public Health Medicine, Scottish Cot Death Trust. Acknowledgements ASH Scotland and the Health Education Board for Scotland would like to thank Dr Ann McNeill, Dr Martin Raw, Professor Robert West, Dr Colin Harris, Dr James Friend, Dr Scott Lennox, Dr Gavin Stark and the BMJ Publishing Group for their advice and help in the preparation of the Scottish smoking cessation guidelines. v

8 Summary of recommendations Smoking is the largest single cause of preventable serious ill-health and premature death in Scotland. These recommendations form the basis for an effective programme, within the NHSiS, to tackle the use of tobacco. It is recommended that they should be assessed for incorporation within future arrangements for quality and effectiveness by the Scottish Executive Health Department. The rationale and supporting evidence for each recommendation is explained in the main text with references to source documents. The responsibility of the health professional is to raise the subject of tobacco use, to assess the smokers readiness to make an attempt to stop smoking, and to provide motivation and appropriate support to help them stop, including advice on the use of nicotine replacement therapy (NRT), which most smokers can use unless there are medical reasons not to (see Section 6). It is the patient s responsibility to stop smoking. The primary care team Section 2 1 Assess and record, using relevant Read codes, the smoking status of patients at every opportunity. 2 When appropriate, advise smokers to stop; assist those interested in doing so; offer follow up; refer to specialist cessation service if necessary. 3 Recommend smokers who want to stop to use nicotine replacement therapy (NRT) and provide accurate information and advice on NRT. Smoking cessation specialists Section 3 4 Intensive smoking cessation support should, where possible, be conducted in groups, should include coping skills training and social support, and should offer around five sessions of about one hour over approximately one month, and follow up. 5 Intensive smoking cessation support should include encouragement to use NRT, with clear advice and instruction on how to use it. Hospital staff Section 4 6 Patients should be advised of hospitals tobacco policies before admission. 7 Routinely assess and record the smoking status of patients on admission. vi

9 Discharge documents should record smoking status and any advice and action taken whilst in hospital. 8 When appropriate, advise smokers to stop; assist those interested in doing so; refer to specialist cessation support on discharge, if necessary. 9 Hospital patients who smoke should be offered help in stopping smoking, including the provision of NRT. All health professionals Section 5 10 The smoking status of all patients (current, ex or never smoker) should be consistently recorded as an essential element of their medical history. 11 Health professionals and medical coders should use either the new ICD10 classification to record tobacco use as Z72.0; the harm due to tobacco use as code F17.1; tobacco dependence as F17.2; and tobacco withdrawal state as F17.3: or relevant Read codes to record tobacco use. 12 Assess and record the smoking status of patients at every opportunity. 13 When appropriate, advise smokers to stop; assist those interested in doing so; offer follow up; refer to specialist cessation support if necessary. 14 Recommend smokers who want to stop to use NRT and provide accurate information and advice on NRT. Pharmacological aids Section 6 Nicotine replacement therapy (NRT) 15 Smokers should be encouraged to use NRT, with support, as a cessation aid (except when contraindicated). It is effective and safe if used correctly. 16 Health professionals who deliver smoking cessation interventions should give smokers accurate information and advice on NRT. Bupropion 17 Smokers should be encouraged to use bupropion, with support, as a smoking cessation aid (except when contraindicated). It is effective and safe if used correctly. 18 General Practitioners should give smokers accurate information and advice on the use of bupropion as an aid to smoking cessation. vii

10 Priority groups Section 7 Pregnant smokers 19 Pregnant smokers should be given firm, clear and consistent advice to stop smoking throughout pregnancy, and offered assistance to stop smoking. 20 The NRT sublingual tablet and lozenge are final options for pregnant smokers who are unable to give up smoking without nicotine substitutes. 21 A randomised, controlled trial of NRT in pregnancy should be set up through the CSO in Scotland. Smokers on low incomes 22 Programmes to support low income smokers should be given high priority. 23 Clinicians have discretion to provide NRT for smokers on a low income, where appropriate, and this should be continued for as long as is considered beneficial. Young smokers (under 16 years) 24 Smoking cessation interventions for young people should be developed and evaluated. 25 The role NRT can play as part of smoking cessation interventions for young people should be evaluated. Older smokers (65 years and over) 26 Age should not be a factor in providing advice to stop smoking. 27 Health professionals should assess and record the smoking status of older patients and offer advice about stopping when appropriate. 28 Cessation interventions shown to be effective with the general population should be adapted for use with older people and NRT offered when appropriate. Smokers with mental health problems 29 Cessation methods used with the general adult population should be modified as necessary for use with smokers with mental health problems and evaluated. 30 NRT should be considered when appropriate and its use carefully monitored and evaluated. Training of health professionals Section 8 31 All health professionals providing smoking cessation support should receive appropriate levels of training. 32 Tobacco education and smoking cessation should be part of the core curriculum of the basic training of all health professionals. viii

11 33 Training should be a core part of a smoking cessation programme in all health board areas. Protected time and funding should be built into this programme. 34 Accredited courses for smoking cessation specialists should be developed and national standards adopted. Commissioners of health services Section 9 35 To produce cost-effective and significant health gain in the population, evidence-based smoking cessation interventions should be commissioned. These interventions should be designed around a stepped care approach, ranging from brief interventions within primary care to specialist services for those who require more intensive support. 36 Review current practice, identify needs, and provide core funding to integrate smoking cessation into health services; plan a cessation strategy with public health specialists and other relevant agencies; seek advice from smoking cessation specialists. 37 A specialist cessation service should be established within each health board area. 38 Smoking cessation training should be core funded and prioritised within existing training budgets. 39 Make provision to ensure that NRT is available to hospital patients who need it, in conjunction with professional advice and cessation support. 40 Encourage all health care providers to support community initiatives aimed at reducing tobacco use and to promote a supportive environment for smoking cessation interventions. 41 Require all services, departments, and clinics to introduce systems to maintain an up to date record of the smoking status of all patients (current, ex, never smoker) in their (paper or electronic) notes. 42 Ensure that all health care facilities have effective tobacco policies. 43 Work with clinicians to put systems in place to audit smoking cessation interventions throughout the health care system. ix

12 Contents About these guidelines Summary of recommendations iv vi 1 Introduction 1 2 The primary care team 7 3 Smoking cessation specialists 10 4 Hospital staff 14 5 All health professionals 16 6 Pharmacological aids 18 Nicotine replacement therapy 18 Bupropion 22 7 Priority groups 24 Pregnant smokers 24 Smokers on low incomes 26 Young smokers (under 16 years) 27 Older smokers (65 years and over) 28 Smokers with mental health problems 29 8 Training of health professionals 30 9 Commissioners of health services Other issues 37 Gender differences 37 Weight gain 37 Carbon monoxide monitor 37 Other interventions 38 References 40 Appendix One 44 Appendix Two 46 Appendix Three 47

13 1 Introduction Smoking is the largest single cause of preventable serious ill-health and premature death. In Scotland it causes an estimated 13,000 deaths each year 3. Over the last 10 years there has been a significant fall in the number of adults who smoke. However, recent data from the General Household Survey 4 show a small increase in the UK smoking rates between 1994 and 1996 from 30% to 32%. Data from the 1995 Scottish Health Survey found that 35% of Scottish adults smoke cigarettes 5. In contrast there has been little reduction in smoking rates amongst young people. The proportion of 15 year old girls who are daily smokers rose from 12% in 1990 to 24% in Daily smoking rates amongst 15 year old boys rose from 12% to 19% in the same time period 6. New targets were set in the White Paper on Health Towards a Healthier Scotland. Headline targets include a reduction in the proportion of year olds who smoke from the 1995 level of 14% to 12% by 2005 and to 11% by 2010, and a reduction in the proportion of women who smoke during pregnancy from 29% to 23% between 1995 and 2005 and to 20% by A second rank target of a reduction in smoking from an average of 35% to 33% between 1995 and 2005 and to an average of 31% by 2010 was set for adults 7. These replace the targets set in Scotland s Health: A Challenge to Us All 8. The White Paper on Tobacco Smoking Kills was published in December It described a range of tobacco control measures, including taxation and price policy, advertising restrictions, public information and health promotion, and cessation support, which are effective in reducing tobacco use. These guidelines outline how the National Health Service in Scotland (NHSiS) can contribute to a national smoking cessation strategy as part of a multi-agency, multi stranded approach. Evidence-based guidelines The HEA guidelines published in Thorax 1 are based on systematic reviews conducted by the Cochrane Tobacco Addiction Review Group 10 in the UK (hereafter referred to as the Cochrane Library Reviews) and the Agency for Health Care Policy and Research (AHCPR) 11 in the USA. They also draw on the American Psychiatric Association (APA) 12. In line with the AHCPR guideline, recommendations in these guidelines are classified according to the strength of evidence: A Many well-designed randomised controlled trials directly relevant to the recommendation, yielding a consistent pattern of findings. B Some evidence from randomised controlled trials, but not optimal. More interpretation of the evidence was needed. For example, there were not many 1

14 randomised controlled trials, their results were not consistent, and they were not directly relevant to the recommendation. They may not have been directly relevant because, for example, the study population was different. C No evidence from randomised controlled trials but the issue is important enough to merit recommendation which is based on published evidence, expert clinical experience or the expert opinion of the authors and reviewers. The Scottish Intercollegiate Guidelines Network (SIGN) who support the development of evidence-based clinical guidelines for the NHSiS use a similar system for the classification of recommendations 13. The SIGN system also originates from AHCPR but requires a lower level of evidence than outlined above for recommendations to be classified as either A or B. In order to keep these guidelines succinct, the evidence on which most of the recommendations are based is not reproduced, but the key evidence is summarised in the table below. Following the AHCPR approach the improvement in cessation rate over and above that in the control is reported. These figures are calculated from odds ratios reported in the AHCPR guideline and the Cochrane Library Reviews. This is regarded as a robust way of demonstrating intervention effects. For a full discussion of the derivation of the evidence base, readers are referred to the HEA guidelines. A summary of the review method and data on the cost-effectiveness of different interventions is reproduced in Appendix One and Two of this document. Evidence table Intervention element Data source Increase in % of smokers abstinent for 6 months or longer Very brief advice to stop (3 min) by clinician versus no advice AHCPR 11 2 Brief advice to stop (up to 10 min) by clinician versus no advice AHCPR Adding NRT to brief advice versus brief advice alone or Cochrane 10 6 brief advice plus placebo Intensive support (e.g. smokers clinic) versus no intervention AHCPR 11 8 Intensive support plus NRT versus intensive support or Cochrane 10 8 intensive support plus placebo Cessation advice and support for hospital patients versus usual care AHCPR 11 5 Cessation advice and support for pregnant smokers versus usual care or no intervention AHCPR 11 7 It must be emphasised that the summary evidence table presents only the effects of the individual intervention elements. Broadly speaking, the effects of individual elements are additive. Thus, a treatment package which combines intensive support with NRT can increase long-term abstinence rates by 16% (8% intensive support + 8% NRT) over controls 1. These guidelines are relevant to all tobacco users. 2

15 Smoking cessation guidelines are timely Smoking costs the NHSiS approximately 140 million a year 14 in hospital care alone. Primary care costs of treating smoking-related conditions add to this burden. However, practical, effective and cost-effective smoking cessation interventions are available. Smoking cessation also fits the criteria for developing clinical guidelines. Furthermore, new developments in health care in Scotland are likely to encourage preventative and evidence-based health care. Smoking cessation interventions are effective Smoking cessation interventions are effective as shown in the Evidence table on page Brief advice in primary care, more intensive interventions, NRT and some other interventions have been investigated in randomised controlled trials which have been systematically reviewed. There is a direct relationship between the amount of person-to-person contact and cessation rates 11. Smoking cessation interventions are cost-effective Smoking cessation interventions are very cost-effective 2. They are guaranteed to bring population health gains for relatively modest expenditure, and in the long term they will reduce smoking-related health care costs, releasing resources for other needs. A recent international review 16 found the median societal cost of over 310 medical interventions to be 17,000 per life year gained discounted at 5% (standard economic practice weights immediately saved life years as more valuable, and life years saved in the future as less valuable ). Discounted results for smoking cessation interventions in the UK range from 212 to 873 per life year gained 2. On these figures, even with conservative assumptions, smoking cessation interventions are considerably more cost-effective than most medical interventions. Criteria for clinical guideline development There are established criteria for determining whether guideline development and promotion is appropriate. Five key reasons have been identified for choosing an area: (1) where there is excessive morbidity, disability, or mortality; (2) where treatment offers good potential for reducing morbidity, disability or mortality; (3) where there is wide variation in clinical practice around the country; (4) where the services involved are resource-intensive (either high volume and low cost or low volume and high cost); (5) where there are many boundary issues involved, sometimes cutting across primary, secondary and community care, and sometimes across different professional bodies. 3

16 Smoking cessation interventions meet all these criteria. Guidelines also provide a framework for consistent implementation of recommmendations contained within the White Paper on tobacco throughout the NHSiS. New developments in health care in Scotland The White Papers Designed to Care Renewing the National Health Service in Scotland 19 and Towards a Healthier Scotland 7 indicated the structures and the priorities for the health service in Scotland. Reducing the impact of tobacco by putting smoking cessation into the front line of primary care and reinforcing with specialist services fits in with both the proposed structure of the NHS in Scotland and the priorities identified for it. Since 1 April 1999 most GP practices (and their patients) have been represented within Local Health Care Co-operatives (LHCCs). Objectives of LHCCs include to support the population wide approaches to health improvement and disease prevention which require lifestyle and behavioural change and to support the development of extended primary care teams and the emergence of specialisms within primary care. They will also provide a direct means by which GPs and their teams and community nurses can work in co-operation with other health and social care professionals, and play a pivotal role in the planning and delivery of local health strategies. Towards a Healthier Scotland identified heart disease, stroke and cancer as priority health topics and placed particular emphasis on inequalities in health. Smoking is a major risk factor for all of these Big 3 killers and is most prevalent in disadvantaged groups. Action to tackle the priority areas was outlined in the White Paper and tobacco was specifically targeted, with measures such as banning advertising of tobacco products complementing new services to help smokers quit. These guidelines set out what service commissioners and providers in the NHSiS can do to promote effective and cost-effective smoking cessation and assist the development and implementation of policies set out in Smoking Kills 9 the UK White Paper on tobacco. Why smoking cessation guidelines are needed for Scotland In 1995 the Scottish Health Survey found that only 16% of male and 21% of female cigarette smokers had been given medical advice to give up smoking in the previous year. No information on the provision of cessation advice to pregnant smokers in Scotland is available but a 1996 Health Education Authority (HEA) survey 20 found that only 39% of pregnant smokers said they had received advice about smoking cessation. From these data, we conclude that there is scope to place much greater emphasis on smoking cessation in routine NHS care in Scotland. 4

17 A number of barriers to action have also been identified. These include lack of time, perceived lack of skills, the perception that success rates are low and limited access to research findings In addition, smoking cessation is not required activity within the health promotion part of GPs contracts and so activity is dependent on the enthusiasm and experience of the individual practitioners. Smoking cessation needs to be integrated into routine NHS care, and this will require the entire NHSiS to raise the priority given to smoking cessation activities. The perception that cessation interventions are not effective may discourage some health professionals from providing smoking cessation services. Appreciating the difference between success rates and reach may help. Intensive treatments that achieve high cessation rates but reach limited numbers will usually produce fewer ex-smokers than less intensive approaches that reach many smokers. Brief advice from GPs (defined by the AHCPR review as up to three minutes) may only encourage about 2% more smokers to stop when compared with normal care control, but this figure, if applied to all GPs in Scotland, would be extremely worthwhile. Using very cautious and conservative assumptions, we estimate that if, in the coming year, all GPs advised 50% of their patients who smoke to stop, using established protocols including the recommendation to use NRT, this would lead to approximately 4-5 extra ex-smokers for each GP, and an additional 17,000 extra ex-smokers in Scotland, at an estimated cost of about 700 per life year gained 2. The precise figures depend on the research study used, but the message is clear: smoking cessation interventions are extremely worthwhile. Developing guidelines for smoking cessation was a key recommendation of A Smoking Cessation Policy for Scotland 22 published by ASH Scotland and HEBS in The HEA guidelines were written for the English health care system, which although very similar to that in Scotland has important differences in management structures. Scottish smoking cessation guidelines are therefore required. Research, evaluation and monitoring The movement towards evidence-based medicine has resulted in an increased emphasis on the need for high quality research Although these guidelines are based on rigorous research, there is an ongoing need for research which underpins, updates and improves clinical practice. In view of this, a national research strategy is needed to support the development of smoking cessation services in Scotland. Based on 3660 GPs with an average list size of 1554, of whom approx 80% are over 15 years of age. With a smoking prevalence of 37% in 1995 this gives approx 460 smokers on each GP s list. If 50% are given brief interventions and 2% stop as a result, this would result in an average of 4.6 extra ex-smokers per GP. Scottish Office Home & Health Department. Health in Scotland 1998, The Stationery Office, Edinburgh

18 Research is needed to evaluate new treatments, training and implementation strategies. As well as the evidence to support the value of smoking cessation interventions by GPs, there is also evidence to indicate that many other health professionals can be effective in providing smoking cessation interventions However, more research is still required to evaluate the role of practice nurses, midwives, health visitors, pharmacists, health promotion specialists, dentists and other health professionals. Research is also needed to determine how transferable evidence of the effectiveness of smoking cessation interventions is to specific sub-groups within the smoking population. In particular, research into the effectiveness of NRT as a cessation aid in pregnancy is urgently required because of the consequences smoking has for the outcome of the pregnancy and the health of the baby after delivery. We also know little about the role NRT could play in reducing rather than eliminating tobacco consumption 27 and whether it could be effective as part of a harm reduction strategy Community-based interventions are more difficult to evaluate. However, they have a central role to play in supporting cessation activity throughout the health care system. Furthermore, it has been demonstrated that some community-based interventions can be very cost-effective in producing health gain 2. Common standards are required to evaluate services and concerted effort is required to monitor the outcome of local services Local programmes offer potential for community-wide smoking cessation services and both qualitative and quantitative data are required 30. Finally, if service delivery is to be improved, health boards need to collect data on outcome and on costs to enable assessment of cost-effectiveness 2. Clinical audit also needs to become standard practice if the impact of the recommendations in these guidelines is to be assessed. Keeping the guidelines up to date The Scottish guidelines will be updated in 2002/03 or earlier if new evidence becomes available. At the time of going to press, the HEA guidelines on which these guidelines were based are being revised. 6

19 2 The primary care team About 90% of all contacts between patients and the NHS take place in primary care 26 with approximately 80% of the population consulting their GP at least once a year 29. Consultation rates are higher for smokers 31. They are also high for pharmacists, with about 68% of the population visiting their pharmacist at least monthly 32. Dentists also see large numbers of patients, many of whom will have smoking-related conditions. Primary care is clearly where smoking cessation advice and support should be focussed with the routine provision of brief advice, assessment and follow up, including advice on NRT and how to use it. Brief advice from a GP is effective 11. Even if it only helps about 2% more smokers to stop (compared with normal care), applied nationally to 50% of smokers in the coming year, this would lead to about 4-5 extra smokers stopping for each GP, or potentially 17,000 throughout Scotland (see page 5 above). Smokers who cannot stop with brief advice should be referred to a specialist cessation service. Having a referral system in place makes healthcare professionals more confident and therefore more likely to raise the subject of smoking in the first place 11. The recommendations below are for the whole primary care team. Teams will differ in how responsibilities and roles are divided. However, the centrality of the doctor-patient relationship and the respect people have for their doctor on health matters 29, means that GPs should play a central role, at least in raising the issue of smoking and advising smokers to stop. Although more research is needed on the role of community pharmacists, they are also part of the primary care team 29 and are in a strategic position to offer smokers advice and support, especially since many smokers will purchase NRT from them. Brief advice on smoking cessation in primary care (and other settings) should be the first part of a stepped care approach where the level of intervention and support is tailored to the smokers motivation to quit and their level of dependency. The essential components of brief advice to quit are: Ask about smoking at every opportunity; Advise all smokers to stop; Assist the smoker to stop; Arrange follow up and appropriate referral if required. 7

20 Ask all patients should have their smoking (or other tobacco use) status established. Smoking status (current, ex, never smoker) should be recorded for all patients using Read codes and changes noted as necessary. Patients identified as having used tobacco within the past 12 months should have their smoking status checked at every opportunity. This should be done after the main purpose of the consultation has been addressed 12. There will be a proportion of smokers for whom it might not be appropriate to mention smoking at every visit for example when treatment for an episode of illness requires regular visits to the surgery, repeatedly asking about smoking could deter patients from keeping appointments. Equally, there is a danger that the quality of the doctor patient relationship could be harmed by the constant mention of smoking 33. Advise all smokers of the value of stopping smoking and the risks to health of continuing. The advice should be clear, firm, and personalised. When a smoker has indicated no interest in stopping smoking, this advice should be brief and include a statement such as well, if and when you change your mind, you know that we will be happy to help you try. Assist if the smoker would like to stop, then help should be offered. A few key points can be covered with the smoker in 5-10 minutes. Set a date to stop: stop completely on that day. Review past experience: what helped, what hindered? Plan ahead: identify likely problems, make a plan to deal with them. Tell family and friends and enlist their support. If appropriate plan what you are going to do about alcohol. Try NRT: use whichever product is best suited to the patient s smoking behaviour and personal preferences. If lack of time prevents this, patients should be invited to make another appointment for this specific purpose. Further advice could include offering a booklet on how to stop. A number of practical guides are available from health promotion departments in every health board area and typically include advice on making an action plan, reasons for stopping, avoiding relapse and coping with stress. The HEBS Smokeline ( ) offers additional support, advice on services and treatments (based on a Scotland-wide database). A self-help guide on stopping smoking is sent to callers, who are also invited to phone back if they want further support. 8

21 If the patient is interested in using NRT, sources of additional advice include pharmacists. Some pharmaceutical companies which supply NRT also provide helplines. Further information on NRT can be found in Section 6. Information about smoking cessation resources can be obtained from local health promotion units. Arrange Offer a follow up visit in about a week, and further visits after that if possible. The clinician offering the initial brief advice does not necessarily need to provide the follow up. Indeed there is benefit in widening the range of practitioners involved 11. Most smokers make several attempts to stop before finally succeeding (the average is around 3-4 attempts 34 ) thus relapse is a normal part of the process. If a smoker has made repeated attempts to stop and failed, experienced severe withdrawal, and/or requested more intensive help, consider referral to a specialist cessation service. This constitutes the higher intensity and higher cost intervention of a stepped care approach. Recommendations for the primary care team 1 Assess and record, using relevant Read codes, the smoking status of patients at every opportunity. 2 When appropriate, advise smokers to stop; assist those interested in doing so; offer follow up; refer to specialist cessation service if necessary. 3 Recommend smokers who want to stop to use NRT and provide accurate information and advice on NRT. Strength of evidence: A 9

22 3 Smoking cessation specialists The cornerstone of the stepped care approach is the routine provision of brief advice in primary care. However, one of the main effects of this will be to motivate attempts to stop, rather than to increase cessation rates and many smokers will be unable to stop without more intensive help. These will usually be heavier smokers, more at risk of smoking-related disease. When smokers need more help than is available from the primary care team, they should be offered referral to a specialist service 35. Although this could be located in general practices, this has not been a popular or practical option 36. A district-wide smoking cessation programme in which brief interventions in primary care are supported by a specialist clinic has been described and evaluated by Michael Russell and colleagues 37. Intensive smoking cessation programmes of this kind have been shown to be effective 11 and, like all smoking cessation interventions, extremely costeffective in producing population health gain, even more so than most medical interventions 2. The evidence reviewed in the AHCPR guideline indicates that there is a dose response relationship between intensity of support (length and content of sessions as well as duration of course) and cessation rates. However, practical constraints of time and funding will determine the level of service offered. A specialist service should deal with motivation to stop, techniques for coping with the urges to smoke and relapse prevention, and should include social support and offer follow up. Self-help materials may help. Cessation support can be effectively delivered by skilled and experienced professionals irrespective of discipline. Most smokers referred to a specialist service should be offered or encouraged to use NRT unless there is a medical reason for them not to. There are two core functions of a specialist service: helping smokers who cannot stop with brief interventions; and training and supporting other health professionals to deliver smoking cessation interventions in the most effective way. The specialist service should also be a source of expert advice and provide resources to primary care teams and hospital staff working with smokers 11. To do this, the service should build strong links with health professionals in all parts of the health service. 10

23 The specialist service should also be highly visible within the community it serves. The service should work with existing community-based groups and services as well as with people referred from primary care. Smokers who need extra information and support should be able to access the service directly. Specialist services should include one or more smoking cessation specialists. They may come from many different health care backgrounds but all should have received smoking cessation training. They will spend a significant proportion of their working time helping people stop smoking or training others to undertake smoking cessation interventions. At present there are a few established courses but we would recommend that these should be evaluated and accredited, with national standards adopted. Content of specialist cessation treatment 38 Most specialist services provide treatment in groups because it is usually more costeffective. In addition, group members can motivate each other to maintain an attempt to stop and learn from each other s experiences. A programme for a stop smoking group often involves five weekly evening sessions over four to six weeks. The first meeting is introductory with participants expected to stop before the second session. NRT is discussed and sometimes provided at the first session. After this, meetings focus primarily on input from group members. They discuss their experiences of the past week, including difficulties encountered, and offer mutual encouragement and support. The sessions are participant orientated, facilitated by the therapist who will encourage interaction and mutual support outside formal sessions. During sessions there can be several conversations at the same time and, with this approach, groups can accommodate people and tend to work better with such numbers 1. When the course is completed follow up meetings can be offered, for example, two, three, six, and 12 months from the beginning of the course. Sessions take about one hour on average and two therapists run the groups together if possible. Some form of self-help materials 39 may be provided. Whether or not follow up meetings are arranged, participants should be asked to complete evaluations at 3, 6 and 12 months. Success rates should be reported on the basis of those still not smoking after one year, as a percentage of those who enrolled on the course. Although group-based interventions are effective, provision can be problematic and numbers of participants can fall off dramatically during the course. To counteract this some specialists encourage participants to keep coming even if they resume smoking. In addition, in many areas in Scotland low population density means it may be necessary to recruit group members over a long period before there are sufficient people to form a group. 11

24 When group provision is impractical or there are smokers who do not want or are unable to attend a group, then they should be offered individual treatment. More research is required into the effectiveness of other models of specialist support, but an analysis of 25 studies which compared the cessation rates for smokers enrolled into groups with those given one-to-one counselling suggests similar cessation rates of about 15% 11. One-to-one counselling can take different forms, but many practitioners use much of the content of a typical stop smoking group. Some offer additional telephone support, either client or therapist initiated. The length of each session and the number of sessions may need controlling, especially if the client is not making any quit attempt, but the AHCPR guideline recommends 20 to 30 minutes with 4 to 7 sessions. Recommendations for smoking cessation specialists 4 Intensive smoking cessation support should, where possible, be conducted in groups, should include coping skills training and social support, and should offer around five sessions of about one hour over approximately one month, and follow up. 5 Intensive smoking cessation support should include encouragement to use NRT, with clear advice and instruction on how to use it. Strength of evidence: A 12

25 Notes 13

26 4 Hospital staff Smoking cessation interventions with hospital inpatients help about 5% more smokers to stop compared with usual care (see Evidence table on page 2). Thus, the evidence supports providing cessation help for smokers in hospital. A hospital stay should be treated as an opportunity to help smokers stop. Smoking can interfere with recovery 11, and evidence is accumulating of the benefits of stopping smoking before surgery 40, radiotherapy 41, and in people with smoking-related disease 42. Health commissioners and managers should therefore ensure that hospitals have effective tobacco policies which provide supportive environments for patients to stop smoking (see Section 9). We recommend the same basic approach for hospital staff as for other health professionals, that is, to ask, advise, assist, and arrange help if needed, including the provision of NRT. All patients should have their smoking status recorded as an essential element of their medical history and their readiness to quit assessed when they come into hospital as an inpatient or outpatient. In addition, systems which facilitate effective identification of smokers should be introduced. When hospital admission is planned for elective surgery, pre-surgery assessment clinics should be used to assess the smoking status and where appropriate to give advice on stopping smoking prior to coming into hospital. Most smokers should be given brief advice about stopping and offered support and, if required, NRT. There will be some exceptions for example, patients in some psychiatric settings and patients with lung cancer. However, even with these patients, smoking status should be recorded. When a patient is discharged from hospital, information about cessation attempts and advice given should also be included in the discharge letter so that smoking cessation can be followed up by the primary care team. 14

27 Recommendations for hospital staff 6 Patients should be advised of hospital s tobacco policies before admission. 7 Routinely assess and record the smoking status of patients on admission. Discharge documents should record smoking status and any advice and action taken whilst in hospital. 8 When appropriate, advise smokers to stop; assist those interested in doing so; refer to specialist cessation support on discharge, if necessary. Strength of evidence: C 9 Hospital patients who smoke should be offered help in stopping smoking, including the provision of NRT. Strength of evidence: A 15

28 5 All health professionals The involvement of health professionals in offering smoking cessation interventions should be based on factors such as access to smokers, level of training, experience, and commitment, rather than professional discipline. Most of the research on brief advice has been conducted with GPs because of their central role within the NHS which gives smokers such access to them. However, in much of the UK research on intensive cessation support the therapists were psychologists and specialist nurses. The evidence reviewed in the AHCPR guideline 11 shows that many professions can deliver effective smoking cessation interventions. Forty-one studies were reviewed which compared interventions delivered by different professions with either self-help materials alone or a no-intervention control. Evidence was found for the effectiveness of interventions delivered by GPs, cardiologists, other physicians, dentists, nurses, pharmacists, psychologists, and social workers. There was also increased success when a variety of health professionals co-operated in giving advice, support and follow up 11. Recording the smoking status of all patients increases smoking cessation interventions by health professionals 11 and seems a logical precursor to further interventions. The recording systems should promote liaison amongst different clinics, services and professions to try to improve continuity of care. While all health professionals can provide smoking cessation interventions, their ability to deliver effective interventions will be increased by training. However, the training needs of different health professional groups will vary greatly. Teaching about tobacco and smoking cessation should be part of the core training for all health professionals. Health boards will also need to give careful consideration to the training needs of different professional groups. The allocation of funding for training is a key recommendation for health commissioners. We recommend that health boards review training needs and that, in addition to the training provided by health promotion services which is typically in brief interventions, training should be a key function of specialist cessation services (see Section 8). There is also a need for more research on the role and training requirements of practice nurses, midwives, health visitors, pharmacists, dentists, and dental hygienists in delivering smoking cessation interventions because of their wide access to smokers, and perhaps other professions also. The sheer scale of the tobacco problem requires appropriate agencies to work together and health professionals to work in partnership with the voluntary sector. 16

29 Recommendations for all health professionals 10 The smoking status of all patients (current, ex or never smoker) should be consistently recorded as an essential element of their medical history. Strength of evidence: A 11 Health professionals and medical coders should use either the ICD10 classification to record tobacco use as Z72.0; the harm due to tobacco use as code F17.1; tobacco dependence as F17.2; and tobacco withdrawal state as F17.3: or relevant Read codes to record tobacco use. 12 Assess and record the smoking status of patients at every opportunity. 13 When appropriate, advise smokers to stop; assist those interested in doing so; offer follow up; refer to specialist cessation services if necessary. 14 Recommend smokers who want to stop to use NRT and provide accurate information and advice on NRT. Strength of evidence: B 17

30 6 Pharmacological aids Two kinds of pharmacological products are licensed as aids to smoking cessation in the UK, nicotine replacement therapy (NRT) and bupropion (Zyban). Nicotine replacement therapy Nicotine replacement therapy provides smokers with an alternative source of nicotine at a much lower dose than tobacco and reduces the severity of symptoms associated with nicotine withdrawal. It approximately doubles cessation rates compared with controls (placebo or no NRT). However, the greater the intensity of adjunctive support provided the greater the effectiveness of NRT 11. In primary care NRT doubles cessation rates from approximately 5% to 10%, and from approximately 10% to 20% in intensive settings. All NRT products gum, patch, nasal spray, inhalator and buccal tablet have similar success rates 43, and there is no evidence yet favouring one product over another. However, the efficacy of NRT is dependent on it being used for sufficient time and in sufficient strength. Treatment periods of 8 weeks have been shown to be as effective as longer periods of treatment 44 but the impact of one or two weeks treatment without any extra support is unclear. Evidence is also emerging of the effectiveness of combinations of different NRT products and of NRT in combination with other drugs, such as bupropion 47. NRT is safe 48 and few become long-term users. It can be routinely recommended to smokers who wish extra help with withdrawal symptoms. The choice of product will depend on practical and personal considerations. In the UK, some NRT products gum, patch, inhalator and buccal tablet are available as pharmacy-only medicines. Two milligramme nicotine gum is also available from other retail outlets. Nicotine nasal spray is available only on private prescription. The current situation in relation to the availability of NRT on NHS prescription is more complex. The majority of NRT products have been withdrawn from NHS prescription through the blacklisting procedure but medical practitioners are free to prescribe a few new products which have been introduced recently. NRT costs about the same as smoking 20 cigarettes a day. This has been used to argue that smokers must therefore be able to afford NRT. Although this may be true for many, it assumes that all smokers can afford to smoke. In the UK the highest smoking rates are found in the most disadvantaged groups, who are estimated to spend around 14% of their disposable income on tobacco 49. Members of this group are also more dependent on nicotine and find it more difficult to stop. It has also been shown that cost affects uptake and acts as a deterrent to NRT use 50. Doctors can write a private prescription for NRT. This saves the patient having to pay VAT. NRT will also be available free for a limited period to those on low incomes, when the initiatives in the White Paper Smoking Kills 9 are implemented. 18

31 Box 1 When to use NRT NRT is most effective when the following conditions are met: Patient is motivated to quit within 1 month. Patient agrees to stop tobacco use completely with the start of NRT. Previous quit attempts have failed because of withdrawal symptoms. Source: Institute for Clinical Systems Integration, Health Care Guideline 51 Health professionals should not regard the advice to use NRT as an option requiring no more input than signing a prescription, as the more support provided, the greater the effectiveness of NRT. Who should use NRT? Except for medical reasons (detailed below) NRT can be used by all smokers. Although most research on NRT has been conducted with people who smoke at least 15 cigarettes a day, the patch and 2mg gum appear to be effective with lighter smokers in research trials 11. Clinicians should discuss the implications of the use of NRT and ensure that it does not interact with prescribed medicines nor is it contraindicated by any medical conditions that patients may have. Who should not use NRT? The current expert view is that NRT is likely to be safer than smoking However, at present in the UK pregnancy is a contraindication for the use of NRT products, though recent reports from Norway and North America suggest that NRT is safe for use in pregnancy (see Section 7). NRT is also contraindicated with cardiovascular disease. The package inserts of several products available in the UK advise people who have heart disease (and some other specified conditions) not to use the products without first talking to their pharmacist or doctor. The health professional can then make an assessment of the risks and benefits of using NRT. The position is less clear for young people. Some products, for example, the patch and the inhalator, are not recommended for people under 18 years, but this age restriction does not appear in the instructions for use of nicotine gum. 19