The National Institute for Health and Care Excellence (NICE) has recommended wider use of licensed nicotine replacement therapy (NRT) for smokers who struggle to quit, in landmark national public health guidance on how healthcare professionals should help smokers who find it difficult to give up.

Tobacco harm reduction (PH45)

Setting an abrupt quit date and quitting smoking altogether is still the best and healthiest option, but for many smokers this can be difficult to achieve, especially for those who are highly dependent on nicotine. Nicotine inhaled from smoking tobacco is highly addictive, but it is primarily the toxins and carcinogens in tobacco smoke – not the nicotine – that cause illness and death. There are therefore other ways of reducing the harm from smoking, even though they may include temporary or long-term use of licensed nicotine-containing products. These products are a safe and effective way of reducing the harm from cigarettes, and NRT products have been shown in trials to be safe for at least 5 year’s use.

The guidance is the first in the world to recommend a pragmatic harm reduction approach and advice that NRT such as patches and nasal sprays can be used to help hardened smokers stop smoking without giving up nicotine or reduce the amount they smoke but feel unable to give up in one step.

One in five adults in England smoke, and around two-thirds of people who smoke say they would like to quit This NICE guidance is about helping people, particularly those who are highly dependent on nicotine, who:

• may not be able (or do not want) to stop smoking in one step;
• may want to stop smoking, without necessarily giving up nicotine; and
• may not be ready to stop smoking, but want to reduce the amount they smoke.

The guidance has been developed for commissioners, managers and practitioners with public health as part of their remit, organisations that provide education and training, manufacturers and retailers of licensed nicotine-containing products. It is especially aimed at those, such as community pharmacy teams, involved in providing advice about stopping smoking, including those working in stop smoking services, and may be of interest to members of the public, especially those who wish to stop or reduce the amount they smoke. There are 14 recommendations, each of which has actions, and several include those to be taken by pharmacy staff, especially if involved in stop smoking services.

Using licensed nicotine products, often in combination, can help people reduce the amount they smoke and also increase their chances of giving up smoking all together. However, they are often not used correctly so NICE advises that health professionals and advisors explain to people how to use them properly to control cravings. They should also reassure people that it is better to use nicotine products and reduce the amount they smoke than to continue smoking at their current level.

Although existing evidence is not clear about the health benefits of smoking reduction, those who reduce the amount they smoke are more likely to stop smoking eventually, particularly if they are using licensed nicotine-containing products.

Harm reduction approaches covered by the guidance includes:

• Stopping smoking, but using NRT for as long as necessary;
• Cutting down to quit, either without for as long as necessary or without NRT;
• Smoking reduction, with or without NRT; and
• temporary abstinence from smoking.

The recommendations cover awareness-raising, advising on, providing and selling licensed nicotine-containing products; self-help materials; behavioural support; and education and training for practitioners. Licensed nicotine products, such as patches and gum, should be offered through the NHS to people who smoke and are struggling to quit, to help them cut down on cigarettes, by healthcare professionals to help encourage greater uptake, either by prescription of through stop smoking services. The cost of this to the NHS is greatly offset by the cost of treating smoking-related illnesses which is around £2.7 billion a year. Over 79,000 deaths in England each year are due to smoking tobacco.

Accompanying the guidance are additional tools:

• A baseline assessment which is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations;
• A costing report and template, produced to estimate the financial impact to the NHS of implementing the guidance in England. The costing work focuses on the recommendations that require the most resource to implement or will generate the most savings.

The guidance does cover pregnant women or recommend the use of electronic cigarettes as they are not currently regulated by the Medicines and Healthcare products Regulatory Agency (MHRA), but an announcement by MHRA on e-cigarettes is due next spring. MHRA is also currently preparing guidance on PGDs.

For LPCs considering discussions with a Local Authority (LA) about these recommendations and possible inclusion within stop smoking services, then the following issues may need consideration:

• Public health guidance is not subject to a mandatory requirement regarding funding so whilst tools have been provided to estimate the scope and cost of implementing the guidance, no additional money has been allocated to accommodate these NICE recommendations. Therefore to take any actions forward, the LA will have to find funds out of the existing ring fenced budget for public health services which may result in reductions elsewhere, or budget activity for the next financial year. Any estimated savings generated may be factored in;
• There has not yet been any change to the national outcomes data recorded for stop smoking – it is still based on 4 week quits. Separate recording will be required; and
• Implementation of NICE public health guidance is not compulsory, but the NHS, LAs, public, private and voluntary sectors in England should take it into account. There are no deadlines set within the guidance, and therefore it may be reviewed in line with service review, as the recommendations are intended to support ad extend the reach and impact of existing services.

NICE publishes several different types of documents for public health:

• Public health briefings, which are produced for LAs and others and which can be used to support the development of Joint Health and Wellbeing Strategies, alongside JSNAs. Nine have been issued in the last year and five are in development;
• Public health guidance, which is aimed at all with a role within NHS public health, makes recommendations for populations and individuals on activities, policies and strategies that can help prevent disease or improve health. The guidance may focus on a particular topic (such as smoking), a particular population (such as schoolchildren) or a particular setting (such as the workplace).  NICE has issued public health guidance since 2007; and
• Public health quality standards, which will be based on existing public health guidance and developed as a tool for use by LAs. The first three standards, currently under development, will cover reducing tobacco use in the community, preventing harmful alcohol use, and strategies to prevent obesity in adults and children, and will consist of a series of statements designed to drive and measure improvements in healthcare. The first public health quality standard on stopping smoking is expected to be published in August 2013.

Other types of NICE guidance include clinical guidelines, intervention procedures, medical technologies and technology appraisals, and it is only the latter which is enforceable, usually three months from the date of publication.

NICE actively seeks feedback from those involved in implementing its guidance, and full details of the guidance can be found at https://guidance.nice.org.uk/PH45

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