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Tobacco harm Tobacco harm reduction: NICE reduction: NICE
guidance and recent guidance and recent developmentsdevelopments
Linda BauldLinda Bauld
Outline Outline
Where we are nowWhere we are now Background to guidanceBackground to guidance Key recommendationsKey recommendations Economic analysisEconomic analysis Considerations Considerations Gaps Gaps
Where we are nowWhere we are nowQuitting behaviourQuitting behaviour
Source: West, 2013, www.smokinginengland.info (data for England only)
Where we are nowWhere we are nowCutting downCutting down
Source: West, 2013, www.smokinginengland.info (data for England only)
BackgroundBackground
NICE guidance has played an NICE guidance has played an important role in supporting the important role in supporting the NHS and other organisations to NHS and other organisations to introduce and deliver evidence-introduce and deliver evidence-based tobacco control interventions based tobacco control interventions
This has included guidance for This has included guidance for smoking cessation interventions and smoking cessation interventions and services, but to date these have been services, but to date these have been aimed at supporting people to stop aimed at supporting people to stop smoking in one step. smoking in one step.
BackgroundBackground The Department of Health asked NICE to The Department of Health asked NICE to
produce this guidance produce this guidance A Programme Development Group was A Programme Development Group was
formed and met to consider the evidence formed and met to consider the evidence and develop the guidance over two years. and develop the guidance over two years.
Draft guidance was published on October Draft guidance was published on October 2424thth 2012. 2012.
A consultation and fieldwork period A consultation and fieldwork period followedfollowed
The amended final guidance was published The amended final guidance was published on June 5on June 5thth2013. 2013.
Focus of GuidanceFocus of Guidance The guidance aims to reduce the
illnesses and deaths caused by smoking tobacco among people who smoke and those around them. People who smoke can do this by: stopping smoking cutting down prior to stopping smoking smoking less abstaining from smoking temporarily.
Licensed Nicotine Products
The harm reduction approaches set out in the guidance can involve substituting the nicotine in tobacco with nicotine from less harmful, nicotine-containing products.
These include NRT products that are licensed by the MHRA as pharmaceutical treatments for smoking.
There are also unregulated products such as electronic cigarettes. The guidance only recommends use of licensed products recognising that when electronic cigarettes become licensed, they can be recommended for use.
Nicotine-containing products might be used either temporarily or indefinitely and as a partial or complete substitute for tobacco
Nicotine-containing Nicotine-containing productsproducts
The guidance states that:The guidance states that:There is reason to believe that lifetime use There is reason to believe that lifetime use of licensed nicotine-containing products will of licensed nicotine-containing products will be considerably less harmful than smokingbe considerably less harmful than smokingThere is little direct evidence on the There is little direct evidence on the effectiveness, quality and safety of nicotine-effectiveness, quality and safety of nicotine-containing products that are not regulated containing products that are not regulated by the MHRA. However, they are expected to by the MHRA. However, they are expected to be less harmful than tobacco.be less harmful than tobacco.
Evidence Evidence
The PDG considered a wide range of The PDG considered a wide range of evidence contained in commissioned evidence contained in commissioned systematic reviews and expert systematic reviews and expert briefing papersbriefing papers
Some key examples followSome key examples follow
Cutting down aloneCutting down alone
Source: Godtfredsen et al, Am J Epidemiol 2002;156: 994-1001
A number of studies found little or no health benefits to just cutting down
Cutting down with & Cutting down with & without NRTwithout NRT
Source: Beard, E., & West. R. (2012) Use of nicotine replacement therapy for smoking reduction and temporary abstinence: an update to Beard et al. Addiction, 107, 1185-1187.
• 10 trials pooled using Mantel-Haenszel fixed-effect model • Abstinence outcome of at least 6 months follow-up, ITT analysis• Reduction produced similar quit rates to abrupt cessation, any difference non-significant• Risk ratio for reduction vs abrupt cessation= 0.94, 95% CI= 0.79-1.13.•Risk ratios varied across individual studies suggesting the success of different reduction methods vary.
Cutting down to quitCutting down to quit
Options in the guidanceOptions in the guidance
Stop smoking in one step and then to use licensed nicotine containing products as a substitute for tobacco, possibly indefinitely. Cut down prior to quitting with or without the help of one or more licensed nicotine-containing products. Smoke less with or without the help of one or more licensed nicotine-containing products. Temporarily abstain with or without the help of one or more licensed nicotine-containing products.
Content of Recommendations 1-7
Raising awareness of licensed nicotine containing products
Self-help materials Choosing a harm
reduction approach
Behavioural support
Advising on licensed nicotine-containing products
Supplying licensed nicotine-containing products
Follow-up appointments
Example: Recommendation Example: Recommendation 11
Raising awareness of licensed nicotine-containing Raising awareness of licensed nicotine-containing products to reduce the harm from smokingproducts to reduce the harm from smokingAimed at national regional and local Aimed at national regional and local organisations responsible for public health and organisations responsible for public health and tackling tobacco use who should: tackling tobacco use who should: Raise awareness among the public of the harm caused by smoking and secondhand smoke. Provide information on how people who smoke can reduce the risk of illness and death (to themselves and others) by using one or more licensed nicotine-containing products.
Barriers to implementation: Barriers to implementation: Beliefs about nicotine and NRTBeliefs about nicotine and NRT
Canada Aust. U.K. U.S.
Nicotine causes most cancer (% answering “true”)
41% 45% 49% 44%
Nicotine causes most cancer (% answering “true”) LOW INCOME
46% 52% 57% 51%
NRT might harm health (% agree strongly + somewhat)
37% 33% 25% 33%
Source: Siahpush et al, Tobacco Control 2006;(Suppl III):iii65-70.
Barriers to Barriers to implementation: implementation:
Smoking cessation staff Smoking cessation staff viewsviews
Source: Beard et al, 2012
Content of Recommendations 8-14
Supporting temporary abstinence
People working in closed institutions (such as secure mental health units, prisons)
Staff working in closed institutions
Commissioning stop smoking services
Education and training for practitioners
Point of sale promotion of licensed nicotine containing products
Manufacturer information on licensed nicotine containing products
Economics An economic model was developed to
assess a wide range of potential harm-reduction approaches. All interventions in the model (apart from temporary abstinence with no support) were highly cost effective.
Only when a nicotine containing product is provided for more than 5 or 10 years, and the quit rate is less than 6%, do the costs (to the NHS) potentially outweigh the benefits
ConsiderationsConsiderations The guidance covers primarily individual The guidance covers primarily individual
level approaches to harm reduction. level approaches to harm reduction. These need to be supported by wider These need to be supported by wider tobacco control policies tobacco control policies
The guidance makes clear the current The guidance makes clear the current limitations of the evidence regarding limitations of the evidence regarding NCPs other than NRT & the link with the NCPs other than NRT & the link with the MHRAMHRA’’s works work
The guidance will be rapidly updated to The guidance will be rapidly updated to reflect changes in licensing reflect changes in licensing
GapsGaps
A considerable number of gaps in the A considerable number of gaps in the evidence were identified during the guidance evidence were identified during the guidance development process, particularly around development process, particularly around population level harm reduction strategies, population level harm reduction strategies, the benefits of smoking less, longer term NRT the benefits of smoking less, longer term NRT use (beyond 5 years) and e-cigarettesuse (beyond 5 years) and e-cigarettes
The guidance also includes research The guidance also includes research recommendations, particularly around the recommendations, particularly around the need for surveillance studies of harm need for surveillance studies of harm reduction strategies and impact of these reduction strategies and impact of these strategies on different sub-populations. strategies on different sub-populations.
Thank youThank [email protected]
Acknowledgements: Acknowledgements:
Simon Ellis and other colleagues from NICE, theSimon Ellis and other colleagues from NICE, the
tobacco harm reduction PDG members, Emma tobacco harm reduction PDG members, Emma Beard.Beard.