Tobacco: preventing uptake, promoting quitting and treating dependence

Impact on NHS workforce and resources

The NICE guideline on tobacco: preventing uptake, promoting quitting, and treating dependence was published in November 2021. The guideline recommendations have been reviewed for their potential impact on the NHS workforce and resources.

The guideline covers support to stop smoking for everyone aged 12 and over, and help to reduce people's harm from smoking if they are not ready to stop in one go. It also covers ways to prevent children, young people and young adults aged 24 and under from taking up smoking. The guideline brings together and updates all NICE's previous guidelines on using tobacco, including smokeless tobacco. It covers nicotine replacement therapy and e-cigarettes to help people stop smoking or reduce their harm from smoking. It does not cover using tobacco products such as ‘heat not burn’ tobacco. Please see the guideline for definitions of terms used to refer to smoking, tobacco products, and products that people may use when trying to stop smoking.

Recommendation 1.12.2 was updated in August 2022 to add Allen Carr’s Easyway in-person group seminars as another option to help people stop smoking. The resource impact of the update is expected to vary locally depending on current and future commissioning arrangements.

Recommendations likely to have an impact on resources

The actions most likely to have the greatest resource impact nationally (for England) are in the section on incentives to stop smoking:

• Offer voucher incentives to support women to stop smoking during pregnancy (recommendation 1.20.12).
• Consider providing voucher incentives jointly to the pregnant woman and to a friend or family member (recommendation 1.20.13).
• Ensure staff training in delivering incentive schemes to pregnant women (recommendation 1.20.14).

Context

In 2018, 14.7% of adults in the UK smoked cigarettes. Rates were higher for some occupational groups and those with mental health conditions. Although it has declined since 2011, smoking is still the main cause of preventable illness and premature death in England. In 2017/2018, an estimated 4% (489,300) of NHS hospital admissions in England and 16% (77,800) of all deaths were attributed to smoking.

Smoking-related illness is estimated to cost the NHS £2.6 billion a year and the wider cost to society is around £11 billion a year.

Services are commissioned by local authorities, integrated care systems and clinical commissioning groups. Providers are secondary care, primary care and community local stop smoking services.

Resource impact

Reducing smoking in pregnancy may help reduce costs associated with baby-related complications, hospital admissions, ultrasound, antenatal attendances, and maternal and in-pregnancy complications.

Evidence suggests that out of every 1,000 pregnant women offered voucher incentives, an additional 18% (177 women) will stop smoking. The economic model showed that voucher rewards totalling a maximum of around £400 were cost effective. (The average amount paid is £300 because incentive payments are staggered and not all women will receive the maximum amount.)

In 2019/20 around 5,900 pregnant women referred to stop smoking services set a quit date and received stop smoking support. Based on 5,900 women receiving support and voucher incentives, the resource impact is estimated to be a net saving of £0.2 million for England. The cash cost of the vouchers is estimated to be an extra £1.6 million, offset by £1.8 million capacity savings from a reduction in complications and extra healthcare needs associated with smoking in pregnancy (see table 1).

Table 1 Potential resource impact of NICE-recommended voucher incentives for pregnant women in England

These figures assume no increase in referrals and that voucher incentives increase the proportion of women who stop smoking while on the scheme. Any further investment to improve stop smoking services and referral pathways would increase the number of women accessing services.

Making the case for action

Health inequalities

Smoking is one of the biggest contributors to health inequalities in the UK. Prevalence is highest in the most deprived areas, among people who may have less access to support and face additional challenges to stopping smoking. Equitable implementation of the guideline - including co-design of prevention interventions, support for vulnerable groups such as people with severe mental health conditions, and incentives during pregnancy - could help reduce smoking-related health inequalities. The guideline also recommends research on making interventions engaging and accessible for the groups most in need of support.

Environmental impact

Smoking 20 cigarettes per day for 50 years contributes to climate change by generating 5.1 tonnes CO2e, which to offset, would require 132 tree seedlings planted and grown for 10 years. Producing these cigarettes also uses enough water to meet 3 people’s basic needs for 62 years (1,355m³), see the World Health Organization Framework Convention on Tobacco Control publication on cigarette smoking. Other impacts of cigarette production include land use (displacing food production), pesticide run off causing loss of biodiversity, air pollution, and toxicity affecting people growing and curing tobacco (green tobacco sickness, an illness caused by absorption of nicotine via the skin). In addition, healthcare usage to screen for and manage smoking-related ill health has negative environmental impacts. Reducing rates of cigarette smoking would limit harms to the environment caused by the production, transport, consumption and disposal of tobacco products.

Support to put the recommendations into practice

Support from NICE

• The guideline should be used alongside related NICE guidance such as the NICE technology appraisal guidance on varenicline for smoking cessation and the NICE guidelines on behaviour change: individual approaches, behaviour change: general approaches, behaviour change: digital and mobile health interventions and community engagement: improving health and wellbeing and reducing health inequalities. In November 2021, varenicline was unavailable in the UK. The Medicines and Healthcare products Regulatory Agency published an alert with advice for healthcare professionals.
• When implementing interventions in schools, the NICE guidelines on alcohol interventions in secondary and further education and social, emotional and mental wellbeing in primary and secondary education may also be helpful.
• To identify gaps and areas for improvement, see NICE’s quality standards on smoking: supporting people to stop, smoking: harm reduction and smoking: reducing and preventing tobacco use. These are being updated (expected publication December 2022); see the quality standard development page.

General support

• The NHS Smoking Cessation Service is a nationally commissioned advanced service as part of the Community Pharmacy Contractual Framework. It allows NHS trusts to refer patients to a community pharmacy of their choice on discharge, so that they can continue receiving stop smoking treatment, advice and support.
• Department of Health and Social Care tobacco and smoking policy, regulation and guidance. The government’s tobacco control plan 2017 to 2022 aims to:
  • reduce the number of 15-year-olds who regularly smoke from 8% to 3% or less
  • reduce smoking among adults in England from 15.5% to 12% or less
  • reduce the inequality gap in smoking prevalence between those in routine and manual occupations and the general population
  • reduce the prevalence of smoking in pregnancy from 10.7% to 6% or less.
• An updated Department of Health and Social Care tobacco control plan will be published in the second half of 2022, and will include a smoking in pregnancy return on investment tool.
• The Office for Health Inequalities and Disparities (OHID) CLeaR self-assessment tools help localities measure themselves against best practice, and have been revised to reflect the updated NICE guidance. The CLeaR model offers:
  • a free self-assessment tool for measuring the success of local action to address harm from tobacco
  • an opportunity to bring local partners together to discuss local tobacco control efforts and reinforce efforts and priorities
  • a voluntary peer-assessment process to challenge your self-assessment, with access to a recognised quality mark
  • a chance to benchmark your work on tobacco control over time and against others
  • self-assessments on: stopping smoking in acute settings and maternity; stopping smoking in mental health settings; stopping smoking during and after pregnancy; illegal tobacco and compliance with regulations; niche tobacco products.
• The National Centre for Smoking Cessation and Training (NCSCT) has developed training, assessment and certification programmes covering the knowledge and skills needed to effectively help people stop smoking. It also provides resources for commissioners, managers, and practitioners.

Support on e-cigarettes

• The Department of Health and Social Care information and guidance on e-cigarettes includes:
  • OHIDs vaping in England: evidence updates (updated each spring)
  • UK product and advertising regulations
  • advice on developing vaping policies that maximise the potential of e-cigarettes in supporting smokers quit, while managing risks.
• NCSCT and OHID advice for services on making e-cigarettes (vapes) available outlines the evidence for providing e-cigarettes alongside licensed stop smoking medications such as nicotine replacement therapy (NRT). It addresses common misconceptions and concerns about vaping and offers a checklist for issues to consider when deciding how to provide access to vaping products.

Support on smoking in pregnancy

• The Smoking in Pregnancy Challenge Group’s evidence into practice briefing (being updated in line with this NICE guideline) supports commissioning incentive schemes and gives both commissioners and practitioners a set of ‘lessons for practice’ to consider before launch. It sets out:
  • impacts of smoking in pregnancy
  • evidence for smokefree pregnancy incentive schemes
  • ‘lessons for practice’ based on schemes that have been implemented, including requirements for successful implementation.

Note that external websites and resources referred to in this statement have been identified as potentially useful resources to help implement specific recommendations from the guideline. NICE has not made any judgement about the methodology, quality or usability of the websites or resources.