National Institute for Health and Clinical Excellence. Smoking Cessation Intervention Draft Recommendations Stakeholder Consultation Table

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1 National Institute for Health and Clinical Excellence Smoking Cessation Intervention Draft Recommendations Stakeholder Consultation Table 25 January February 2006 Stakeholder Implementation Planning Mtg, NICE Recommendation 1 6 Please could the recommendation clarify whether it is necessary for GPs to advice patients face-to-face or whether it would be adequate to send out letters to known smokers as it is practice in some areas. Diabetes UK 6 Are there any other services that could also be useful to refer patients to other than only the NHS Stop Smoking Service? Diabetes UK 6 Again, a prescription of NRT but other therapies not. It could be appropriate to refer people to other therapies such as hypnotherapy and acupuncture. People may have already tried NRT and it not worked for them so other therapies could be more effective. Ash Scotland 6 Evidence suggests that people who receive either one to one or group support, combined with treatment such as nicotine gum and patches, are up to four times more likely to quit and find this effective than willpower alone. It is concerning to see that Recommendation 1 suggests that GPs should offer a prescription for NRT and/or offer a referral to the NHS Stop smoking service. Such guidance could discourage referrals to NHS Smoking Cessation Services and leave many individuals with NRT, but no support and therefore less of a chance to quit. The Smoking Cessation Guidelines for Scotland (2004) recommend that GPs ensure they have spoken with known smokers, advised them to stop and offered treatment (in the form of a referral to an NHS SCS). It also states that smokers should be strongly recommended to use NRT or buproprion (Zyban), accompanied with the appropriate support and advice, unless contraindicated. ASH Scotland 6 The guidance should state that GPs require suitable training and knowledge of where patients can be referred to in order to receive support with their quit attempt and also an appreciation of the type of support which is offered by different services. There has been discussion within Scottish Smoking Cessation services This has been clarified. The recommendations have been reworded. Intensive treatments will be assessed in the programme guidance. Treatments other than NRT will be assessed as part of the programme guidance on smoking cessation. Following consultation, PHIAC is recommending an approach similar to that recommended in the Smoking cessation guidelines for Scotland. Practitioners are advised to follow the existing advice on Bupropion set out in the NICE technology appraisal (no. 39) which will be updated as part of the programme guidance. Noted. 1

2 Practice Airways Group 6-7 that many referrals made by GPs are inappropriate for the different levels of support needed by the patient and also at what stage the patient is in terms of motivation to quit. Several of the recommendations state that smoking cessation advice should be given without specifying what the best advice is. As advice is the most simple and common effective smoking cessation intervention performed by all HCPs, NICE needs to consider this carefully. Simple advice to stop smoking has evidence to support it, but clinical experience points to the greater efficacy of advice on how to stop smoking ie using support and treatment as a trigger to an evidence based quit attempt. This advice deserves special consideration and is worthy of research directed by NICE. See comments below on the 30 second approach. The recommendation has been reworded following consultation. Practice Airways Group Practice Airways Group The consultation document refers to different kinds of primary care professional at different points. Should this point really only apply to GPs, or could this be broadened out to encompass all primary care professionals? 6 6 We strongly question the value of advising treatment without behavioural support. Evidence suggests that NRT approximately doubles the baseline quit rate, but the baseline quit rate is largely dependent on level of support. Whereas an unsupported ( willpower alone ) quit attempt gives a one year quit rate of 3-4%, an attempt with maximal support gives a rate of 10-15%. Adding NRT to an unsupported quit attempt approximately doubles the rate to give an 8% rate whereas adding NRT to maximal support can give a rate of 15-20%. Therefore, treatment alone is likely to be a waste of resource, which is not advisable in PCTs where there are considerable budgetary pressures. Treatment alone may also potentially undermine patient confidence for future attempts. It is not sensible to advocate treatment without some form of support. Indeed, most smoking cessation treatment studies are based on treatment AND support, not treatment in isolation. Support may be more important than treatment in increasing the chances of success. 6 We question whether there is evidence that blanket advising of patients to stop is effective. The key factor to establish before the person is given any help to quit is whether they are motivated to quit. It would not be best practice for prescribing to take place before readiness to quit had been assessed, and while this is to some The recommendations have been broadened to embrace all healthcare professionals. Following consultation, PHIAC is recommending a step-down approach that prioritises the most effective treatment. There is evidence that opportunistic advice given by GPs is effective. The recommendations have been phrased to take account of the differences between 2

3 Practice Airways Group extent covered in the phrase where appropriate this needs to be explicitly emphasized 6 Footnote - We are somewhat surprised that there is no evidence for bupropion here. Its complete omission from this guidance without adequate explanation may lead people to believe it has no role at all. This is not necessarily in the interests of patients and perhaps it should be clarified where it does have a role. The footnote, as it stands, is somewhat inadequate. It may be that it has been excluded because there is little evidence of its effectiveness without behavioural support. However, we believe that all treatments are more effective if the patient is motivated to stop, AND has behavioural support. On this basis, we would question the rationale for separating out NRT and bupropion here. professional groups. The recommendations have been reworded and now refer to pharmacotherapies. Practitioners are advised to follow the existing advice on NRT and Bupropion set out in the NICE technology appraisal (no. 39). Royal College of Practitioners Royal College of Practitioners GlaxoSmithKline 6 Suffolk Stop Smoking Service 6 And/or is open to different interpretations and might be clearer Noted. It has been clarified. 6 support from might be better than referral to SSS Noted. Although we recognise that bupropion is currently licensed in combination with motivational support, it does remain an option for GP s to prescribe and is recommended in current NICE guidance. We therefore suggest that this should be an explicit option within this recommendation. In addition Note 2 to this recommendation refers to a lack of evidence on buproprion in short term interventions. A real world smoking cessation study with bupropion in general practice in the UK does support the efficacy of this intervention with relatively low levels of support. The results of this study were submitted to NICE as part of the original review of bupropion and NRT. 6 We are concerned about the statement if appropriate they should offer a prescription for NRT. If a prescription is offered at brief intervention this is no longer a brief intervention. This could impact both the effectiveness and economics of the delivery. A brief intervention does not offer the expectation of follow-up. In our service we do not support the supply of a prescription unless behavioural support is in place and a quit date is set. The reasons are: As this evidence was not submitted as part of the consultation or identified in the peer reviewed literature, it could not be taken into account. The advice set out in the original review regarding Bupropion is more consistent with what would be considered an intensive intervention. The recommendations have been revised as a result of the consultation. 3

4 West Midlands Smoking Cessation in Pregnancy & WM Tobacco Control Networks Stop Smoking Service Kent 1. The likely success of the person quitting will be reduced 2. Prescribing costs are monitored against reported 4week quit activity to try and improve the reporting of quit attempts. Although the recommendation says if appropriate I feel it could undermine our efforts to ensure that people get behavioural support and all quit attempts are reported so they form part of the 4week quit data, this will also then make the intervention more cost effective as we will have measurable outcomes which are likely to be lacking otherwise. There would be a danger of seeing prescribing costs going up and 4 week quit data going down. 6 The NHS stop smoking service is not a single service, rather it includes a number of services. 1 Practitioners GPs should, at least once a year, advise all patients who smoke to stop. If appropriate1, they should offer a prescription for NRT2 and/or offer a referral3 to the NHS Stop Smoking Service. they should offer a referral first A report by the London Health Observatory states that there should be: Systematic offers of smoking cessation intervention for all smokers at the earliest opportunity. 4 This has been clarified in the recommendations. Following consultation, PHIAC is recommending a step-down approach that prioritises the most effective treatment. Referral to smoking services could be initiated by the GP if waiting time for surgery is shorter than eight weeks otherwise patient information should be given out at first out patient appointment. Preoperative Smoking Cessation: A model to estimate Potential Short Term Gain and Reductions in Length of Stay London Health Observatory September 2005 East Lancashire Hardly any evidence is presented about the role of referral to NHS Stop Smoking PHIAC took the decision to refer to the

5 Public Health Network West Midlands Smoking Cessation in Pregnancy & WM Tobacco Control Networks Services or the effectiveness of these services. Despite this, recommendations 1-4 advocate referral to these services. In my opinion it is wrong to make recommendations in an evidence-based guidance document that are not based on evidence presented in the document. Recommendation 2 6 A good strategy would be to target pre-op patients for smoking cessation support. A letter could be sent advising the patient and their family that the Trust operates a smoke free policy and offering cessation support before they are admitted to hospital. Intensive cessation support should also be available to patients in these situations ASH Scotland 6 If appropriate, support and advice should be given prior to a patient arriving for hospital treatment. Smoking is known to affect recovery following surgery and therefore patients should be prepared for entering an area where smoking is not permitted. GlaxoSmithKline 6 Suffolk Stop Smoking Service Recommendation 1 contains an explicit recommendation that GPS should offer a prescription for NRT. We believe that a similar recommendation should be made to hospital clinicians, e.g. If appropriate, patients should be offered a prescription for NRT and/or referred to the NHS Stop Smoking Service. This is particularly relevant for in-patients, who are unlikely to be able to access the NHS Stop Smoking Services. This is supported by the fact that in Appendix A, this recommendation is supported by Evidence Statement 7 which refers to the efficacy of NRT in the context of brief interventions. See also our comment on recommendation 7, below. 6 It would be helpful in this context to include a recommendation that hospitals should offer NRT, both to support quitting and as a means of relieving nicotine withdrawal in a smokefree environment. NHS services in the recommendations even though the evidence of its effectiveness was not covered in the review. Current evidence suggests that the services offer the most effective treatment available. The services, as well as other intensive treatments, will be assessed in the programme guidance. Thank you. We will pass this suggestion on to the NICE Implementation Team. Thank you. We will pass this suggestion on to the NICE Implementation Team. The recommendations have been revised following consultation. The link between support for quitting and smokefree policies is mentioned in the guidance and will be made more explicit in the supporting documents on 5

6 Newcastle PCT 6 Effectiveness-Recommendation 2 states that hospital clinicians should advise smokers to stop and offer help and advice but in recommendation 7 it states that there is no evidence that brief advice alone is effective with hospital inpatients. Sounds like a contradiction? CPHVA 6 On the back of policies and protocols within hospital needs to be a robust training programme to include both brief intervention and treatment advice so that all staff are committed to support patients. Not sufficient just to ban smoking within Hospital areas. Follow up crucial via primary care and should perhaps be actively put in place (not sufficient to send a letter that might take weeks to reach GP surgery). Stop Smoking Service Kent Practice Airways Group Suffolk Stop Smoking Service GlaxoSmithKline 6 Effectiveness and economics. 2 Hospital Clinicians Hospital clinicians should advise smokers to stop and offer help and advice soon after they have started receiving hospital treatment. If appropriate, patients should be referred to the NHS Stop Smoking Service. Patients undergoing hospital follow-up should be offered cessation help and advice before or at the time of admission. It is preferable to stop smoking 8 weeks before treatment if possible. (acknowledging differences between elective & emergency surgery.) Recommendation 3 6 We disagree. The nurse needs to assess readiness to quit, and only refer to the stop-smoking service those smokers who are motivated to make a quit attempt (not refer those who are not yet ready to quit). 6 Similar to recommendation 1. If a nurse prescriber is trained to deliver stop smoking interventions then she can refer to herself but should only prescribe when the patient has set a quit date and agreed to support. Mixing prescribing with brief intervention can confuse the issue and although a small number may go off and successfully quit as a result we will have no way to measure that. If follow up is organised it is no longer a brief intervention NICE technical appraisal no 39 says NRT should normally only be prescribed as part of an abstinent contingent treatment in which the smoker makes a commitment to stop We believe the recommendation that nurses with suitable training offer a prescription for NRT should be strengthened and made more explicit, as follows: implementation. This has been amended, but just to clarify, the studies demonstrating effectiveness with physicians included hospital doctors as well as GPs. This issue will be addressed in the supporting documents on implementation as well as the programme guidance. This recommendation has been changed, but the guidance does not refer to the timing of pre-operative brief interventions. This has been amended in the guidance. This has been amended in the guidance. A step-down approach has been recommended after consultation. 6

7 Royal College of Practitioners Stop Smoking Service Kent West Midlands Smoking Cessation in Pregnancy & WM TCN Practice Airways Group Nurses with suitable training could should offer an NRT prescription in lieu of a referral to those services where appropriate who are unable or unwilling to attend the specialist services NRT has been shown to be efficacious as part of a brief intervention (your Evidence Statement 7). Many smokers will be willing or able to participate in the NHS Stop Smoking Services. All smokers should be encouraged to use the maximum amount of support, but should be offered NRT regardless. 6 What does whenever possible mean? This has been amended Nurses Nurses in primary and community care should, whenever possible, advise all smokers to stop and refer them to the NHS Stop Smoking Service. Nurses with suitable training could offer an NRT prescription in lieu of a referral to those services where appropriate. Nurses who have been trained as NHS stop smoking counsellors may refer to themselves where appropriate. A referral should be offered first or then NRT with support Recommendations 3 and 4 Intensive cessation support should also be available to patients in these situations. 6 Rec 3 (page 6) states nurses with suitable training could offer an NRT prescription in lieu of a referral, and Rec 4 (page 7) states the same for pharmacists Following consultation, PHIAC is recommending an approach that prioritises the more effective treatment. Intensive support will be dealt with in the programme guidance. These have been amended. We are not clear why this should be in lieu of a referral. Why could the nurse not refer to other services run by the practice or PCT? As commented above, where possible NRT prescribing should take place alongside behavioural support (e.g. through the NHS stop-smoking services) Considering the recent parliamentary vote on smoking in public places, should we The issue of training will be raised with 7

8 be more bullish about the training of nurses in smoking cessation? All nurses who have a higher than average population who smoke (or high risk - smokers; or special group - children) should be trained or have easy access to training. Nurses with some training are very skilled at helping (see BMJ ABC Series of Smoking, 2003) CPHVA 6-7 Greater consideration of a coordinated approach within a local community area so that there are professional networks ensuring that staff from different areas are working together, know who is trained within the area so that if brief intervention is offered then active and prompt referral made ensuring choice to best suit the individual patient. This should also include the health advisors so that their time is effectively used to both ensure patients are encouraged to access but also well supported through the process. Resources i.e. numbers of staff trained and able to deliver within local areas also determined. Effective and economic. Department of Health Department of Health Department of Health British Dental Association National Pharmacy Association Ltd Recommendation 4 7 Should recommend that pharmacists give advice to reflect the new Contractual Framework for Community Pharmacy which stipulates that pharmacists given brief structured interventions on lifestyle issues including smoking either linked to prescriptions or to support self-care the NICE Implementation Team. Linkage between various professional groups and local communities will be raised with the NICE Implementation Team. This has been changed in the guidance. 7 Reword last sentence to read: Nurse and pharmacist prescribers who have had The wording of the recommendation has the appropriate training could offer a prescription. been changed. 7 Community pharmacists sell NRT over the counter Thank you for pointing out this oversight. 7 We would like to suggest that the role of dentists be recognised in the document, perhaps in Recommendation 4 of Section (p. 7). This currently reads: Other health professionals, such as pharmacists should, where practicable, recommend smokers to use the NHS Stop Smoking Service, and could be changed to: Other health professionals, such as pharmacists and dentists and their teams should, where practicable, recommend smokers to use the NHS Stop Smoking Service 7 We are pleased that the role of pharmacy is acknowledged in recommendation 4. However, we feel that in the light of the current evidence-base and national policy, that community pharmacy smoking cessation services should be given exactly the same recognition as nurse-led services in recommendation 3. In addition, please acknowledge that community pharmacy is an ideal vehicle to use to reach manual working groups, pregnant smokers and hard to reach populations since premises Dentists have been specifically mentioned in the guidance. The context within which brief interventions and referrals are delivered has been strengthened in the guidance. The role of pharmacists within this has been recognised. 8

9 are typically located in the heart of local communities, with pharmacy staff typically being employed from the local community. Current evidence base There are now numerous community pharmacy-led smoking cessation services. For example those described in Pharmaceutical Journal articles at Major public health role for pharmacy. PJ Smoking cessation voucher scheme involves whole pharmacy team. PJ Smoking cessation can be used as a service delivery model for pharmacy. PJ Thank you, noted with interest. The NPA is currently working on a practical toolkit to capture the learning from the established community pharmacy smoking cessation services, in order to spread best practice and save PCTs reinventing the wheel when they consider commissioning such an enhanced service under the new pharmacy contract. This toolkit will also include service evaluations. National policy The DH policy document Choosing health through pharmacy: A programme for pharmaceutical public health describes the key role that community pharmacy plays in smoking cessation services. This document is available at and listed below are some of the references made to community pharmacies role in this document: There is a strong evidence base for the effectiveness of pharmacy-led stopsmoking programmes and NHS stop-smoking services in community pharmacy are a major success story, in some cases enabling PCTs to achieve their stop-smoking targets. Community pharmacists can additionally become one of the main providers of specialist NHS stop-smoking services. PCTs, particularly those with low quit rates, should consider setting up pharmacy-led services. We will notify the NICE Implementation Team. 9

10 National Pharmacy Association Ltd The strategy includes a table mapping the list of priorities for pharmacy based services on the PSA targets, and the size of the potential population health impact by utilising pharmacy. An extract of this table is: Priority PSA target Pharmacy Population Reducing smoking Reduce adult smoking rates to 21% or less by 2010, and to 26% in routine and manual groups. contribution Opportunistic brief advice. No-smoking campaigns. Specialist NHS Stop Smoking Service including NRT, etc. health impact Major impact As stated above, community pharmacy is an ideal vehicle to use to reach manual working groups, pregnant smokers and hard to reach populations since premises are typically located in the heart of local communities, with pharmacy staff typically being employed from the local community. This is acknowledged in Choosing Health through Pharmacy which states that, for example: In some communities and neighbourhoods, the pharmacy, perhaps with the post office, is the main community resource. Counter assistants in the pharmacy are often recruited from the local population, know the area well and may speak the language of a significant local ethnic minority. They have front-line customer contact and their public health role could be developed significantly. Health improvement services in pharmacies will have most impact on reducing inequalities if investment is targeted by PCTs on pharmacies in the areas with the worst health indicators. Services to reduce inequalities can be provided directly by pharmacists and their staff, or by making their premises available to other professionals. We (the DH) want to see a development role for pharmacists and their staff in supporting health trainers. Pharmacies could be used as a setting where health trainers are available. As part of their signposting role, pharmacists and their staff could put Thank you. 10

11 people in touch with a health trainer. They could also identify local people who might be interested in becoming personal health trainers. NPA comment: we are aware of some pharmacy staff who are being put forward to become health trainers themselves. GlaxoSmithKline 7 Feedback to chair of PHIAC following Implementation Planning We believe the recommendation that other healthcare professionals with suitable training offer a prescription for NRT should be strengthened and made more explicit, as follows: Other health professionals, such as pharmacists and dentists should, where practicable, recommend smokers to use the NHS Stop Smoking Service. Those with suitable training could should offer a prescription of NRT to smokers in lieu of a referral to stop smoking services where appropriate those unable or unwilling to attend the specialist services; those unable to prescribe should recommend NRT (via prescription or OTC purchase). Other health professionals, such as pharmacists should, where practicable, recommend smokers to use the NHS Stop Smoking Service. Those with suitable training could offer a prescription of NRT to smokers in lieu of a referral to stop smoking services where appropriate. It was suggested that dentists be specified alongside pharmacists as illustrative examples to ensure their involvement, especially as they will be expected to deliver health promotion as part of their new NHS contracts. This addition would be justified given evidence statements 3 and 4. Recommendation 5 ASH Scotland 7 It should be clearer which Health Professionals should be collecting/recording the smoking status of those individuals who are not ready to stop and how/where this should be recorded. The guidance should also state whether the National Minimum Dataset would be used to record this information. Newcastle PCT 7 Effectiveness-Recommendation 5 states that there is no evidence that an approach based on a psychological model of stages of change is more effective than other approaches when giving brief advice. What does other mean? We use the stages of change and the 5A s approach-should we be using something else, if so The recommendations are now based on a step-down approach with the most effective treatment having the highest priority. The wording of the recommendation has been changed. The recommendations state that all health professionals advising smokers should record this information in the clinical records. Guidance on data collection will be raised with the NICE Implementation Team. Other refers to the comparator interventions in the evaluation studies, many of which were multi-component. In the absence of evidence showing that 11

12 Practice Airways Group GlaxoSmithKline 7 Stop Smoking Service Kent what? 7 It is slightly concerning that the DoH has recommended the psychological model of stages and funded many nurses across the UK on the Prochaska and DiClementi work (the paper produced in 1970 was a description of the authors experience rather than research). Hence it is somewhat unclear what the advice here on this means. This was compounded by the recommendation of recording and review annually - is there evidence for this last statement on recording and reviewing? There is a lot in this recommendation and there may be some merit in splitting it out into several. Some NRT products are now also indicated for use in smokers currently unable or not ready to stop smoking abruptly, to be used as part of a programme to reduce smoking prior to stopping completely; other products will likely also be similarly indicated in the near future. We believe that a statement recommending its use in this way should be included, eg For those ready to quit immediately, healthcare professionals should consider offering or recommending NRT to help the smoker cut down their smoking as part of their quitting strategy 5 Advice giving Advice to stop smoking should be pragmatic and sensitive to the individual s needs and circumstances. There is no evidence that an approach based on a psychological model of stages of change is more effective than other approaches when giving brief advice. The smoking status of those who are not ready to stop should be recorded and reviewed with the individual every year. Advice should include information on how to contact the service in the future. Recommendation 6 ASH Scotland 7 We suggest that the wording should be changed from However, when someone presents with a smoking related disease, the advice MAY be linked to it to However, when someone presents with a smoking related disease, the advice SHOULD be linked to it one method is more effective than any other, PHIAC is unable to recommend a particular approach. See above for Stages of Change. In order to ensure that smokers receive appropriate advice and support, the relevant information must appear in their notes. PHIAC considered that in most circumstances it is reasonable to ask patients about their smoking once a year. These issues will be considered in the update of the technology appraisal for NRT and Bupropion. This comment will be passed to the NICE Implementation Team. The wording of this recommendation has been changed. 12

13 Royal College of Obstetricians and Gynaecologists West Midlands Smoking Cessation in Pregnancy & WM Tobacco Control Networks Practice Airways Group Recommendation 7 7 The RCOG supports this recommendation, which defines pregnant smokers as a priority group. We feel other s will be better placed to comment on the other recommendations. 7 Women who continue to smoke in pregnancy are particularly tobacco dependent. Brief interventions may work with women who are less dependent i.e. a number of women do quit in early pregnancy. One explanation is perhaps the way the advice is delivered. If it has been delivered in a judgemental way then it may be less effective. The whole approach to smoking in pregnancy needs to be information, helpful and supportive as opposed to victim blaming. There are qualitative studies in this area e.g Barriers to smoking cessation in pregnancy : a qualitative study by A.Todd in British Journal Community Nursing, 2003, Vol 8, no 2. e.g. Using social marketing to increase recruitment of pregnant smokers to smoking cessation service: a success story by Lowry et al, Public Health, 2004, 118, e.g A survey of pregnant smoker s interest in different types of smoking cessation support by usher et al, in Patient Education and Counselling 54, 2004, Partners and family are also key they should be a target group too. Experience to date demonstrates a need to shift the burden of responsibility from solely the woman to include significant others. There is a need to work in different ways by routinely offering carbon monoxide breath testing to all women in early pregnancy. 7 This states pregnant smokers and hospital inpatients are both priority groups Adolescents and young adults may also be considered priority groups. There is inequity in access to, and outcome within, stop-smoking services among this group. Also, helping young people to quit before they start a family has preventive benefits (e.g. reduced smoking in pregnancy, reduced second-hand smoking in the home, and reduced likelihood of children reproducing their parents smoking behaviour). Specific efforts are warranted to raise the issue with this group, and refer. Thank you. Thank you for highlighting these references. We will pass them on to the NICE Implementation Team. The more intensive interventions will be covered in the programme guidance for smoking cessation. Thank you for your comments, however the focus of the referral from the DH is cessation. Future referrals may deal with prevention. If you would like to make suggestions for future referrals, you may do so on the NICE website at: PPIP, NICE 7 Does the reference to hospital inpatients cover psychiatric hospitals? Yes it did, but the recommendation has now changed. GlaxoSmithKline 7 As a result of MHRA guidance based on a review by a CSM Working Party, NRT The evidence for using NRT during 13

14 Royal College of Nursing contra-indications in pregnancy are to be removed. We believe it is important to give an explicit recommendation regarding the use of NRT in this context. The following is suggested: Stopping smoking is the single most effective intervention for improving the health of the pregnant smoker and her baby. The earlier abstinence is achieved the better. Ideally, smoking cessation during pregnancy should be achieved without the use of NRT. However, for women unable to quit on their own, NRT should be recommended or prescribed to assist a quit attempt. Intermittent dosing products may be preferable as they usually provide a lower daily dose of nicotine than patches. However, patches may be preferred if the woman is suffering from nausea during pregnancy. If patches are used they should be removed before going to bed. We agree that hospital in-patients are also a priority group. As previously noted, hospital inpatients are unlikely to be able to access the NHS Stop Smoking Services. Although there is very little evidence regarding the efficacy of NRT in this specific population (as noted in your evidence review), there is a wealth of evidence demonstrating the efficacy of NRT is a broad range of settings and with varying levels of additional support (NICE Technology Appraisal 39. Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation, March 2002). We therefore believe that this recommendation should include a specific recommendation to prescribe NRT. While we fully appreciate the importance of making Hospital Inpatients and Pregnant Women a priority area and from, our experience of smoking cessation, we know this is a time when the client s motivation is often high and there is a strong focus on improving their health, we do feel there is a missed opportunity to make young people and student a priority group. Many young people will be established smokers well before they leave school. Surely it is better to put helping these young people to stop smoking as a top priority. Children and young people are the groups least likely to be seeing GPs, Primary Care /Community Nurses and Pharmacists and therefore need special targeted initiatives. School Nurses and University/College Health Services have a huge role in encouraging and supporting these young people and ensuring they can access pregnancy will be considered in the update of the technology appraisal for NRT and Bupropion. This recommendation has been changed. The recommendations cover all smokers. Thank you for your comments regarding the role of different professionals (e.g. school nurses). We will pass these on to the NICE Implementation Team. 14

15 Feedback to chair of PHIAC following Implementation Planning meeting East Lancashire Public Health Network Stop Smoking Service Kent Rec 7 support and Nicotine Replacement Therapy. If this were a priority then maybe less pregnant women and in-service patients would smoke. If Pregnant women are to be targeted, Midwives who are in close and regular contact with women over a period of 6-7 month on average are in an ideal position to refer clients to Stop Smoking Services and to develop their skills in supporting women and their families to stop smoking. (It is seen as important to encourage partners or family members in the same home to give up as well as the pregnant woman - this supports her efforts and protects the newborn baby) as such Midwives should be mentioned in the recommendation. Recent work done by the NHS Modernisation Agency (Large Scale Workforce Change Team) into developing the role of Maternity Support Workers has indicated that Smoking Cessation may be a good role for them to take on however I am not aware if evidence is available yet. Scale Workforce Change Team) into developing the role of Maternity Support Workers has indicated that Smoking Cessation may be a good role for them to take on however, we are not aware if evidence is available yet. Pregnant smokers and hospitals inpatients are both priority groups. Both should be encouraged to use the NHS Stop Smoking Services as there is no evidence that brief advice alone is effective with them. Apparently there has been a big push in some areas for hospital clinicians to provide brief interventions and this recommendation might discourage these efforts. Similarly, considerable efforts have gone into encouraging interventions, whether brief or intensive, to support pregnant smokers to quit. Given the wording of the relevant evidence statements (see below) I will seek clarification from the reviewers as to whether they are stating that there is EVIDENCE OF NO EFFECT rather than NO EVIDENCE OF AN EFFECT. This recommendation is correctly based on the evidence of lack of effectiveness of brief interventions in pregnant or hospitalised smokers. However, it also goes onto recommend referral to NHS Stop Smoking Services without presenting any evidence that this is effective for these groups. In my view the recommendation should be limited to the findings presented within the document. 7 Priority groups Pregnant smokers and hospital inpatients are both priority groups. Both should be encouraged to use the NHS Stop Smoking Service, as there is no evidence that The recommendation has been changed. This recommendation has been changed. More intensive interventions will be covered in the programme guidance. 15

16 Feedback to chair of PHIAC following Implementation Planning meeting Practice Airways Group brief advice alone is effective with them. Advice should be given to breastfeeders and partners to expectant and new mothers Recommendations 1,2,3,4,7 There was a general concern that recommendations that included referral only referred to the NHS stop smoking services. In some areas referrals included interventions not provided by the NHS services. As the smoking programme guidance is not limited to consideration of the NHS services perhaps we need to look at this again? Recommendation 8 7 We would recommend giving the PCTs and Trusts stronger guidance along the following lines. PCTs or NHS Trusts will provide regular training and updates for all health care professionals which will enable them to be effective in giving brief advice, or more specialised support as appropriate to the needs of the health care area. The PCTs should evaluate this training and the impact of their training. They will commission appropriate a NHS Stop Smoking Service. Should there also be a recommendation that there is a role for awareness of local services and support which should be part of recommendation 8 and be part of an evaluated local action plan on smoking cessation? As existing evidence suggests that the services offer the most effective decision, PHIAC took the decision to include referral to the services as part of the package of brief interventions. The issue of training will be raised with the NICE Implementation Team. This recommendation has been reworded and it states that local cessation advice and support should be widely available. NHS s and healthcare settings should publicise their smoking policies and deal with people who infringe these. ASH Scotland 7-8 A further recommendation could be added which suggests that relevant professionals should receive training in line with the National Standards. ASH Scotland ASH Scotland would like to see the guidance highlight Training. Despite National training standards existing for England and Wales, Scotland and for Northern Ireland which relate to brief advice/interventions for Smoking cessation, the guidance does not identify this. The guidelines should recommend that relevant Health Professionals receive training in line with these standards in order to ensure that brief advice reflects best practise/evidence base. Evidence already shows that people trained in smoking cessation will be more likely to raise the issue of quitting This will be raised with the NICE Implementation Team. This will be raised with the NICE Implementation Team. 16

17 Taunton Deane PCT Suffolk Stop Smoking Service and implement what they have learnt (from Cochrane review 7 RE Community Pharmacists The draft talks about Pharmacists prescribing NRT. Prescribing by community pharmacists is not yet in existence. Currently Pharmacists can refer or sell NRT to patients. The guidance should not underestimate the aid to quitters given by the sale of NRT. Many PCTs like our own also use Patient Group Directions which allow Pharmacists to SUPPLY (neither sell nor prescribe) NRT to patients. This has enabled community pharmacists to support quitters by supplying NRT to those patients who would not go to a general practitioner or were put off buying NRT due to the Cost. By virtue of their training and position Pharmacists have a very good knowledge of the risks and benefits of NRT. They should be exempt from any extra training requirements in the same manner as GPs are. 7 8 It would be helpful to see a recognition of the need for clinicians to receive training in order to effectively deliver brief interventions. Recommendation 9 CPHVA 8 Re: commissioners in addition to use of socio-demographic and cultural characteristics, needs to be planning of resources i.e. variety of staff who can both provide brief but also more crucially treatment intervention time consuming. Important to have a variety of staff i.e. practice nurses; health visitors; midwives; pharmacists to ensure choice for the individual but also opportunistic advice and follow up. Effectiveness and economics.. Royal College of Practitioners 8 How should commissioners use this information to target services? There is no evidence base to inform the targeting of services and hence this statement is meaningless. Recommendation 10 Department of Health 8 Not all smokers are patients e.g. in a pharmacy setting. Suggest adding patients and clients or and customers. ASH Scotland 8 Detail of what monitoring system should be used by Health Professionals could be outlined here will the National minimum dataset be used for this? It should also Noted. This will be raised with the NICE Implementation Team. The wording of this recommendation has been changed. This recommendation has been changed. The wording has been changed in the guidance. This will be raised with the NICE Implementation Team. 17

18 state which Health Professionals should be accessing this information and explain what the monitoring system needs to be appropriate for. ASH Scotland 8 There should be clear referral pathways to NHS Smoking cessation services from Health professionals and this could be detailed here. CPHVA 8 Information management poor within the community lack of access to IT and systems for many health visitors, school health advisors, midwives. No good just considering GP systems. Need to be realistic and practical in considering access. Effective and economic. A referral pathway has been added to the practice recommendations. Noted. Section 2 Public health need and practice National Pharmacy Association Ltd 10 Under the paragraph that begins It is now government policy that health professionals should refer patients who need support to the service and this is being reflected in contractual changes we would like a statement that captures the fact that a Stop Smoking Service is now one of the possible enhanced services that can be commissioned under the new pharmacy contract (service specification at ASH Scotland 10 The second paragraph should make clear that following up a quit date at four weeks is based guidance to conduct follow-ups for England. England may also benefit from trying to provide longer-term outcomes for smoking cessation in addition to short-term outcomes. Scottish guidance states that Smoking Cessation Services should follow up clients at 4 weeks, 12 weeks and 12 months. ASH Scotland 10 The guidance makes no reference to the National Minimum dataset and carrying out of follow-ups here. This could be a potential source for GPs to both record and monitor the referral process. Section 3 Recommendations for Research Recommendation 12 ASH Scotland 12 It would be valid to have some explanation of why the cost effectiveness of Brief Intervention is required in the studies of effectiveness. We will raise this with the NICE Implementation Team. It may be included in the supporting materials. The NHS Stop Smoking Services (including those provided by pharmacists) will be considered by the NICE programme guidance on smoking cessation. This has been included in section 4.1. This will be raised with the NICE Implementation Team. The cost-effectiveness review identified very few well conducted studies of cost effectiveness. 18

19 Glaxo Smith Kline Department of Health 12 It should be clarified as to whether this refers to brief advice alone or brief advice in conjunction with pharmacological treatment. Recommendation rd bullet: It is likely to be 2007 before pharmacists have had the training and are actually prescribing The definition of a brief intervention is set out at the beginning of the document and includes a combination of brief advice and pharmacotherapy. Thank you for this information. We have had to reference a source which in this case is the CMOs Update of 11/01/06. This gives the date the scheme begins, rather than when it is widely in practice. Department of 12 8 th bullet: Suggest including community pharmacies This has been amended. Health CPHVA 12 Brief intervention advice may be influenced by whether the adviser is a smoker currently, an ex-smoker or a never smoker. This is a question often raised, and the smokers tend to prefer ex-smokers to be delivering the advice. Perhaps another area for proper research. the research questions. CPHVA 12 Enthusiasm, commitment and knowledge about services can be an influence in Noted. See above. how the advice is delivered, the content of that advice, and the individual perception of the smoker about the person delivering the advice. i.e. are they doing it to meet a target or are they genuinely interested in my welfare? CPHVA 12 Brief advice should consist of a standard format supplemented with tailored other advice. The main key points should be to give information about non-judgmental attitude, ability to re-access, free service, treatment on prescription, where to access and how, and generally what goes on. This must be supported by a booklet like I have designed called What you can expect from the stop smoking service. This must be about each individual service as service models differ in design. Ours is also available for viewing on the website at follow the links from local services, community services then stop smoking. CPHVA 12 All individuals in the frontline, including GP receptionists are capable of delivering information but also need a tailored training course on how to speak to smokers and what information to provide. Rather than the national standard for brief intervention training, then this should be decided at local level or may need to be flexible for different staff groups. Characteristics that affect the effectiveness of a brief intervention, which could include the provider, are included in Noted. The issue of training will be raised with the NICE Implementation Team. CPHVA 12 It is time to offer payment for GP s to attend training in brief intervention. It will be This is beyond the remit of this piece of 19

20 the only way but make it mandatory and give them accreditation. Stop smoking coordinators receive lots of feedback from patients about unsatisfactory comments which are off putting for them. It s not always what you say but the way that you say it! CPHVA 12 Has NICE considered allied health professionals delivering brief advice such as speech therapists, podiatrists, radiographers, opticians (in light of recent evidence around age-related macular degeneration) etc. West Midlands Smoking Cessation in Pregnancy and WMTCN Royal College of Practitioners 24 There may be a huge resource amongst non-health professional groups who may be ideally placed to deliver brief advice e.g. Citizens Advice, benefits agency etc So long as they are committed and appropriately trained this may be an area that requires investigation 12 Why do we need a population-based study to determine why brief advice does not work with pregnant smokers. This kind of question is probably better answered by smaller scale studies using mixed methods approaches. Diabetes UK 12 When looking at the effectiveness of brief advice with and without cessation aides, what is the follow up period looked at in order to judge effectiveness? It states elsewhere in the document that a follow up time of 4 weeks is used in the NHS Stop Smoking Service. This time is quite short and it would be good to have a longer follow up time than this. Diabetes UK 12 NRT is mentioned here but should there also be a mention of buproprion? People may have already tried to stop smoking and used NRT and not been successful. Buproprion may be suitable for some people and this should be included in the further research. ASH Scotland 12 In addition to the research recommended here, ASH Scotland would like to see the guidance identify the effectiveness of brief advice with those individuals who have mental health problems and also the effectiveness of brief advice delivered by trained or untrained individuals as valid areas of research. ASH Scotland 12 Bullet point two The need to look at how brief advice works with pregnant smokers should be extended to include brief advice for all minority groups and specific target groups. ASH Scotland 12 The guidance could also benefit from looking at the effectiveness of those services, which are provided, in the local community and non-nhs settings. This could be incorporated into focusing upon brief advice in wider settings. work. The guidance does not exclude any professional groups. It also refers to community workers. Noted. This has been amended. The text states that long-term follow-up should be included in studies of effectiveness. The research questions have been amended. The research questions have been amended. The research questions have been amended. This will be considered as part of the programme guidance on smoking cessation. 20