Implementing the July 2015 NICE Quality Standard to reduce harm from smoking Deborah Arnott Chief Executive Action on Smoking and Health Smoking Cessation in Mental Health conference 20 th October 2015
Harm reduction measures Often viewed as controversial Sexual activity Guidance on safer sex Distribution of condoms Use of recreational drugs Needle exchange schemes Safe injection sites Consumption of alcohol Recommended limits unit counting Facilitating consumption nominated drivers 2
Why tobacco harm reduction? Not all smokers are ready or willing to quit: Around a third of smokers will try to quit each year Two thirds will not Support beyond the traditional quit model has been shown to help people reduce risk to themselves, others and increases their chances of quitting completely
Deprived communities have most to gain The recommendations are particularly relevant to people who are highly dependent on nicotine and groups where smoking prevalence is higher than average. Examples include: people with mental illness, people from lower socioeconomic groups Tobacco: harm reduction approaches to smoking, NICE, 2013
Smoking has declined least among most disadvantaged 80 70 CIGARET T E SM OKING BY DEPRIVAT ION IN GREAT BRIT AIN: GHS 1 9 7 3 & 2 0 0 9 72 % prevalence 60 50 40 30 20 10 42 12 46 20 52 32 57 46 55 1973 2009 0 0 1 2 3 4 M os t a fflue nt Poore s t DEPRIVAT ION SCORE
Increased odds of smoking by nearly any indicator of disadvantage
d e p r e v. t c Poorer smokers are more likely to be highly dependent 350 Plasma cotinine by depriv ation in cigarette smokers: HSE 2006-2012 Plasma cotinine (ng/ml) 300 250 200 Mean ± 95% CI 0 1 2 3 4 DEPRIVATION SCORE
Gap in smoking rates will remain unless we do something different 40 35 33 32 32 34 31 31 30 29 30 32 Cigarette smoking % 30 20 10 20 21 20 19 17 19 18 17 17 Routine & manual Non-routine 28 29 27 16 16 15 16 16 25.3 11.3 0 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 Year
PH45 tobacco harm reduction June 2013 NICE published PH45 guidance on Tobacco Harm Reduction Does include: Recommendations for helping smokers not yet ready or willing to quit Guidance for the whole system not just stop smoking services Doesn t include: Recommendation on e-cigarettes Prescriptive guidance for practice
Other relevant NICE guidance Smoking cessation in secondary care: acute, maternity and mental health services (PH 48) Smoking cessation services (PH10) Identifying and supporting people most at risk of dying prematurely (PH15) Workplace interventions to promote smoking cessation (PH5)
Quality standard Statement 1. People who are unwilling or not ready to stop smoking are offered a harm-reduction approach to smoking. Statement 2. People who are unwilling or not ready to stop smoking are advised that health problems associated with smoking are caused primarily by components in tobacco smoke other than nicotine.
Quality standard Statement 3. People who are unwilling or not ready to stop smoking are advised about using nicotine-containing products and supported to obtain licensed nicotine-containing products. Statement 4. 'Stop smoking' services offer harm-reduction approaches alongside existing approaches to stopping smoking in one step.
Harm reduction approaches Types of intervention: Cut down to quit (with or without NRT) Temporary abstinence (with or without NRT) Complete substitution with alternative source of nicotine Nature of interventions: Advice in a mainstream service Support in a mainstream service Self-help materials Support through a stop smoking service
Percentage of smokers reporting a quit attempt in the previous 12 months Increase likelihood of quit attempt as a function of harm reduction activities 80 70 60 50 40 30 20 10 0 Other smokers SR without NRT TA with NRT SR with NRT SR & TA with NRT Source: Beard, E., & West. R. (2012). Addiction
25% Address poor knowledge among public (and professionals) According to what you know or believe, what portion of the health risks of smoking comes from nicotine in cigarettes? 20% 15% 10% 5% 0% None or very small Some but well under half the risk Around half the risk Much more than half the risk Nearly all the risk Don t know
Ensure perceptions of risk don t undermine choice 80% Perception of relative safety e-cigarettes 70% 67% 60% 50% 53% 40% 30% 33% 20% 17% 10% 0% Current electronic cigarette user and ex-smoker Current electronic cigarette user and current smoker Ex-electronic cigarette user and current smoker % who agree electronic cigarettes are a lot less harmful than regular cigarettes Never electronic cigarette user and current smoker
Move smokers towards less risky behaviours Around half the population has ever smoked 57% 4% 6% 34% Ex-smoker Less risk More risk Current smokers Ex-smoker uses e- cigarettes Current smoker uses e- cigarettes
Examples of some projects
Small cut down to quit pilot Mental health unit in Devon
Cut down to quit programme NICE Guidance PH45 Harm reduction approaches to smoking PHE Smoking cessation in secure mental health settings 2015 Working with those not ready to quit Offered cut down to quit as an alternative
Results Residents engaged well with Cut Down To Quit model 7 out of 12 smoking residents and 1 staff member took part 4 quit
Observations Reduction of medication a key motivation Residents were more aware of their physical health, had increased knowledge and selfempowerment Those that did not quit made behaviour changes Partnership working was highly successful Staff became motivated to make further change
ecig-friendly service Leicester City On No Smoking Day 2014 service launched its self as first e-cig friendly service in the country Actively recruited smokers wanting to use e- cigarettes into the service Also changed how they talked about e-cigarettes to those enquiring rather than: we can t recommend them said: we can t supply them Provided advice on purchasing effective products and using them correctly
Results Product Number set a quit date Number successfully quit % Quit Rate NRT 2737 1296 47% Product Number set a quit date Number successfully quit % Quit Rate E-cigarette only 107 68 64% Concurrently with medication 160 92 58% Consecutively with medication 29 23 79% Grand Total 296 183 62%
Observations Recognition in a stop smoking service of e-cigarettes as a means of stopping smoking appears to be a valid means of attracting people to services This may help to increase numbers of people benefitting from behavioural support from experienced stop smoking advisors
Conclusions Harm reduction approaches offer an alternative way to help smokers particularly those highly addicted and not yet ready to quit NICE guidance is a useful framework Organisations should consider the role of electronic cigarettes in supporting smokers to reduce harm to themselves and others
Harm reduction resources Materials to help shape policy jointly produced by PHE, NCSCT, NICE and ASH www.smokefreeaction.org.uk/harmre duct.html Guide on e-cigarettes from NCSCT http://www.ncsct.co.uk/publication_ec igarette_briefing.php and briefings from ASH http://www.ash.org.uk/current-policyissues/harm-reduction-productregulation/regulating-nicotineproducts Harm reduction yammer group email hazel.cheeseman@ash.org.uk