Smoking

Short Text

This pathway covers interventions and strategies to prevent children and young people from taking up smoking and to help everyone who already smokes to quit.

Introduction

This pathway covers interventions and strategies to prevent children and young people from taking up smoking and to help everyone who already smokes to quit. This includes tailored strategies for women who are pregnant or who have recently given birth. It also includes strategies to help adults who smoke who are from a disadvantaged background and, hence, most at risk of dying prematurely.
Activities could take place in a range of places, including workplaces and schools.
Smoking cessation interventions are generally very cost effective, irrespective of the target audience, the methods used to identify and recruit adults or the type of service offered.

Source guidance

The NICE guidance that was used to create the pathway.
Quitting smoking in pregnancy and following childbirth. NICE public health guidance 26 (2010)
School-based interventions to prevent smoking. NICE public health guidance 23 (2010)
Identifying and supporting people most at risk of dying prematurely. NICE public health guidance 15 (2008)
Preventing the uptake of smoking by children and young people. NICE public health guidance 14 (2008)
Smoking cessation services. NICE public health guidance 10 (2008)
Workplace interventions to promote smoking cessation. NICE public health guidance 5 (2007)
Brief interventions and referral for smoking cessation. NICE public health guidance 1 (2006)
Varenicline for smoking cessation. NICE technology appraisal 123 (2007)

Quality standards

Quality statements

Effective interventions library

Brief interventions

The interventions listed below are part of NICE's effective interventions library on public health. The evidence on these interventions was used to develop the recommendations in this pathway. All interventions listed have been identified and appraised using NICE public health methods and processes.
When reading the data, bear in mind that it has been interpreted in a review process, discussed by committee and considered in relation to a range of populations and different experiences in order to develop recommendations. In general, data on interventions is often limited: population studies are expensive to run; follow-up is generally short; studies may have been poorly conducted; reporting is variable and often poor. However, even when effects seem to be small, there can be enormous benefits when an intervention is applied across the whole population.
Where possible, the NICE analysts have calculated a measure of effectiveness from the original studies. These cases are marked 'i' (implied by the data).
1Brief advice from a physician
2Structured advice from a nurse
3Nicotine-replacement therapy as part of a brief intervention

Proactive recruitment to smoking cessation services

The interventions listed below are part of NICE's effective interventions library on public health. The evidence on these interventions was used to develop the recommendations in this pathway. All interventions listed have been identified and appraised using NICE public health methods and processes.
When reading the data, bear in mind that it has been interpreted in a review process, discussed by committee and considered in relation to a range of populations and different experiences in order to develop recommendations. In general, data on interventions is often limited: population studies are expensive to run; follow-up is generally short; studies may have been poorly conducted; reporting is variable and often poor. However, even when effects seem to be small, there can be enormous benefits when an intervention is applied across the whole population.
Where possible, the NICE analysts have calculated a measure of effectiveness from the original studies. These cases are marked 'i' (implied by the data).
1Proactive recruitment using health records
2Proactive recruitment of patients using a questionnaire
3Proactive recruitment as part of cervical screening
4Proactive recruitment of parents
5Proactive recruitment at AIDS and HIV clinics

Successful effective interventions library details

Brief advice from a physician

Key elements of the intervention

5 minutes of advice from a physician as a brief intervention.

Source guidance

Recommendation 3 from Brief interventions for smoking cessation (NICE public health guidance 1).

Effectiveness

For more details on the evidence below, see the NICE systematic review.
Lancaster and Stead (2004), international
Study design Meta-analysis
Final sample size Pooled data from 17 trials
Outcome Odds of quitting attributable to brief advice compared with no advice (or usual care)
Measure of effect OR 1.74 (95% CI 1.48– 2.05); NNT 55 (i)

Costs

For more details on the evidence below, see the NICE economic review.
Cummings et al. (1989) Costs from £37 to £89 per additional quitter. Using a discount rate of 5%, the cost per life year gained ranged from £50 to £122.
Akehurst 1994 Based on average cost-effectiveness, the cost was £296 per quitter, £6,838 per death avoided and £613 per life year gained.

Factors to take account of

Occasionally it might be inappropriate to advise a patient to quit, for example, because of their presenting condition or personal circumstancesFrom Brief interventions for smoking cessation, footnote in section 1..

Impact on health inequalities

The studies included in this systematic review did not report the socio-economic status of the patients. However, differences in the prevalence of smoking between the higher and lower social classes account for over half the difference in the risk of premature death faced by these groupsFrom Brief interventions for smoking cessation, section 2.2..

Structured advice from a nurse

Key elements of the intervention

Up to 10 minutes of structured advice from a nurse, and up to one follow-up visit.

Source guidance

Recommendation 4 from Brief interventions for smoking cessation (NICE public health guidance 1).

Effectiveness

For more details of the evidence below, see the NICE systematic review.
Rice et al. (2004), international
Study design Meta-analysis
Final sample size 6 trials
Outcome 12-month quit rate for nurse intervention compared with usual care
Measure of effect OR 1.76 (95% CI 1.23–1.53); numbers quitting with intervention 84/1282 (7%), control 49/1340 (4%); NNT 34 (i)

Costs

For more details on the evidence below, see the NICE economic review.
Krumholz (1993) Cost-effectiveness was estimated at $380 per quitter. The ICER was $220 per additional year of life saved.

Factors to take account of

Occasionally it might be inappropriate to advise a patient to quit, for example, because of their presenting condition or personal circumstancesFrom Brief interventions for smoking cessation, footnote in section 1..

Impact on health inequalities

The studies included in this systematic review did not report the socio-economic status of the patients. However, differences in the prevalence of smoking between the higher and lower social classes account for over half the difference in the risk of premature death faced by these groupsFrom Brief interventions for smoking cessation, section 2.2..

Nicotine-replacement therapy as part of a brief intervention

Key elements of the intervention

Nicotine-replacement therapy prescribed with low-intensity support.

Source guidance

Recommendation 3 from Brief interventions for smoking cessation (NICE public health guidance 1).

Effectiveness

For more details on the evidence below, see the NICE systematic review.
Silagy, Lancaster, Stead et al. (2002), international
Study design Meta-analysis
Sample Review of 34 randomised trials
Outcome 12-month quit rate
Measure of effectiveness Pooling gum and patch trials resulted in an OR of 1.81 (95% CI 1.61–2.02) compared with low-intensity support and placebo or no nicotine gum. This relative effect was comparable with that obtained with more intensive support. NNT 14 (i)

Costs

For more details on the evidence below, see the NICE economic review.
Akehurst (1994) The ICER of nicotine patches over and above GP counselling was £1252 per quitter, £58,894 per death avoided and £4526 per life year gained.
Stapleton (1999) The ICER of nicotine patches and brief GP advice over and above brief GP advice alone was £398 for patients aged under 35 years, £345 for patients aged 35–44 years, £432 for patients aged 45–54 years, and £785 for patients aged 55–65 years.

Factors to take account of

Occasionally it might be inappropriate to advise a patient to quit, for example, because of their presenting condition or personal circumstancesFrom Brief interventions for smoking cessation, footnote in section 1..

Impact on health inequalities

The studies included in this systematic review did not report the socio-economic status of the patients. However, differences in the prevalence of smoking between the higher and lower social classes account for over half the difference in the risk of premature death faced by these groupsFrom Brief interventions for smoking cessation, section 2.2..

Proactive recruitment using health records

Key elements of the intervention

Proactive recruitment of smokers from health records, followed by provision of advice and information.

Source guidance

Recommendation 1 from Identifying and supporting people most at risk of dying prematurely (NICE public health guidance 15).

Effectiveness

For more details of the evidence below, see the NICE systematic review.
Murray et al (2007), UK
Study design Cluster RCT
Final sample size 24 primary care practices; intervention group 3051, control 3805
Outcomes Proportion of smokers reporting attendance at local NHS stop smoking services, and number of quit attempts
Measure of effect Increased the proportion of smokers reporting attendance at stop smoking services and had a modest effect on the number of quit attempts made, but no significant impact on actual quit rates or reported cigarette consumption
Bentz et al (2006), USA
Study design Observational
Final sample size 15,662 smokers
Outcomes Numbers calling the quit line and accessing tobacco cessation services
Measure of effect 19% called the quit line. Of these, 94% accepted a one-time tobacco cessation intervention from a quit line counsellor
Glasgow et al. (2006), USA
Study design Cohort
Final sample size Study 1, 160; study 2, 531
Outcomes Reach of comprehensive programmes that include a smoking reduction component (rather than just cessation)
Measure of effect Reach increased by 22–39%

Costs

For more details of the evidence below, see the NICE economic review.
Murray et al. (2007) Cost per QALY £2,089 (2007 prices)
Bentz et al. (2006) Cost per QALY £365 (2007 prices)

Factors to take account of

Identifying and supporting people most at risk of dying prematurely summarises the factors NICE's committee considered when developing the recommendations on recruiting people to stop smoking interventions. See paragraphs 3.4–3.7.

Impact on health inequalities

Only Glasgow et al. (2006) reported the socio-economic status of patients, but there is limited discussion of any possible effect on outcomes – despite there being a higher proportion of non-participants with lower education levels.

Proactive recruitment of patients using a questionnaire

Key elements of the intervention

Proactive recruitment of smokers from a questionnaire of existing patients, followed by provision of advice and information.

Source guidance

Recommendation 1 from Identifying and supporting people most at risk of dying prematurely (NICE public health guidance 15).

Effectiveness

For more details of the evidence below, see the NICE systematic review.
Milch et al. (2004), USA
Study design Prospective cluster controlled trial (not randomised)
Final sample size Enhanced (questionnaire) 115, minimal (smoking status recorded) 118, control 411
Outcome Self-reported quit rates at mean follow up of 9.5 months
Measure of effect Enhanced 12% (14/115), minimal 2% (2/118), control 4% (17/411) (p<0.001); NNT 13 (i)

Costs

For more details of the evidence below, see the NICE economic review.
Milch et al. (2003a) Cost per QALY £11 (2007 prices)

Factors to take account of

Identifying and supporting people most at risk of dying prematurely summarises the factors NICE's committee considered when developing the recommendations on recruiting people to stop smoking interventions. See paragraphs 3.4–3.7.

Impact on health inequalities

The trial did not report the socio-economic status of the patients; however, differences in the prevalence of smoking between the higher and lower social classes accounts for over half the difference in the risk of premature death faced by these groupsFrom Brief interventions for smoking cessation, section 2.2..

Proactive recruitment as part of cervical screening

Key elements of the intervention

Proactive recruitment of smokers as part of routine cervical screening, followed by provision of advice and information.

Source guidance

Recommendation 1 from Identifying and supporting people most at risk of dying prematurely (NICE public health guidance 15).

Effectiveness

For more details of the evidence below, see the NICE systematic review.
Hall et al. (2003), UK
Study design Cluster RCT
Final sample size 242
Outcome Report of readiness to stop smoking in the next 6 months
Measure of effect Women sent a brief leaflet were more likely to report that they were ready to stop compared with those:
  • sent an extended leaflet: 75% vs 46% (95% CI 11–48%); NNT 4
  • not sent a leaflet: 75% vs 40% (95% CI 19–52%) NNT (i)
Hall et al. (2007), UK
Study design Cluster RCT
Final sample size Intervention 121, control 121
Outcome Intention to stop smoking in the next month, measured at 2 and 10 weeks
Measure of effect
  • At 2 weeks: intervention 2.86 (SD 1.80), control 2.29 (SD 1.71), adjusted mean difference 0.51 (95% CI 0.02–1.03), p=0.06
  • At 10 weeks: intervention 3.13 (SD 2.04), control 2.24 (SD 1.58), adjusted mean difference 0.80 (95% CI 0.10–1.50), p=0.03
Effect size at 10 week follow up 0.32 (i)

Costs

For more details of the evidence below, see the NICE economic review.
Hall et al. (2003) Cost per QALY £19 (2007 prices)
Hall et al. (2007) Cost per QALY £86 (2007 prices)

Factors to take account of

Identifying and supporting people most at risk of dying prematurely summarises the factors NICE's committee considered when developing the recommendations on recruiting people to stop smoking interventions. See paragraphs 3.4–3.7.

Impact on health inequalities

The study did not report the socio-economic status of the women who agreed to participate. But cervical screening involves the vast majority of women across all socio-economic groups within a certain age range on regular occasions, so this may be a useful way to draw young disadvantaged smokers into considering quitting. Further research with disadvantaged women is required to confirm thisFrom the NICE systematic review.

Proactive recruitment of parents

Key elements of the intervention

Proactive recruitment of smokers as part of their children's paediatric appointment followed, by provision of advice and information.

Source guidance

Recommendation 1 from Identifying and supporting people most at risk of dying prematurely (NICE public health guidance 15).

Effectiveness

For more details of the evidence below, see the NICE systematic review.
Curry et al. (2003), USA
Study design RCT
Final sample size Intervention 156, control 147
Outcome Self-reported quit rate
Measure of effect
  • At 3 months: intervention 8%, control 3% (adjusted OR 2.40, 95% CI 0.85–7.80); NNT20 (i)
  • At 12 months: intervention 14%, control 7% (adjusted OR 2.77, 95% CI 1.24–6.60 using an intention to treat analysis); NNT 15 (i)

Costs

For more details of the evidence below, see the NICE economic review.
Curry et al (2003) Cost per QALY £1126 (2007 prices)

Factors to take account of

Identifying and supporting people most at risk of dying prematurely summarises the factors NICE's committee considered when developing the recommendations on recruiting people to stop smoking interventions. See paragraphs 3.4–3.7.

Impact on health inequalities

Curry et al (2003) identified female smokers accompanying children to paediatric visits in clinics that serve an ethnically diverse population of low income families.

Proactive recruitment at AIDS and HIV clinics

Key elements of the intervention

Proactive recruitment of smokers as part of routine AIDS/HIV clinic appointment, followed by provision of advice and information

Source guidance

Recommendation 1 from Identifying and supporting people most at risk of dying prematurely (NICE public health guidance 15).

Effectiveness

For more details of the evidence below, see the NICE systematic review.
Vidrine et al. (2006), USA
Study design Observational pilot study
Final sample size 49
Outcome Abstinence (not smoking in 24 hours before assessment) and sustained abstinence (not smoking in 7 days before assessment) at 3 months
Measure of effect
  • Abstinence: intervention 29.2% (intervention delivered by cell phone), control 8.5% (usual care) (p=0.040); NNT 5 (i)
  • Sustained abstinence: intervention 16.7%, control 6.4% (p=0.283); NNT 10 (i)

Costs

For more details of the evidence below, see the NICE economic review.
Vidrine et al. (2006) Cost per QALY £175 (2007 prices)

Factors to take account of

Identifying and supporting people most at risk of dying prematurely summarises the factors NICE's committee considered when developing the recommendations on recruiting people to stop smoking interventions. See paragraphs 3.4–3.7.

Impact on health inequalities

Lazev et al. (2004) explore barriers to participating in smoking cessation programmes among low income, HIV-positive smokers.
Vidrine et al. (2006) point out that the clinic served an ethnically/racially diverse population of economically disadvantaged people.

Implementation

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
Quitting smoking in pregnancy and following childbirth: self-assessment tool.
Smoking cessation services: audit support.
Workplace interventions to promote smoking cessation: audit support.
Brief interventions and referral for smoking cessation: audit support.
Varenicline for smoking cessation: audit support.
Workplace interventions to promote smoking cessation: business case.
Quitting smoking in pregnancy and following childbirth: costing template.
School-based interventions to prevent smoking: costing template.
Identifying and supporting people most at risk of dying prematurely: costing statement.
Preventing the uptake of smoking by children and young people: costing statement.
Smoking cessation services: costing template.
Smoking cessation services: costing report.
Workplace interventions to promote smoking cessation: costing template.
Brief interventions and referral for smoking cessation: costing report.
Brief interventions and referral for smoking cessation: costing template.
Varenicline for smoking cessation: costing template.
Smoking cessation services: implementation advice.
Workplace interventions to promote smoking cessation: What you can do to encourage your employees to stop smoking.
Workplace interventions to promote smoking cessation: implementation advice.
Brief interventions and referral for smoking cessation: implementation advice.

Pathway information

Health inequalities

Reducing the prevalence of smoking among people in routine and manual groups, some minority ethnic groups and disadvantaged communities will help reduce health inequalities more than any other measure to improve the public's health.
Although NHS Stop Smoking Services have helped large numbers of people to quit smoking, smoking cessation rates are still lower among people in routine and manual groups compared with those in higher socioeconomic groups. In particular, pregnant women in routine and manual groups and those aged 20 or under may need additional support to give up smoking.
Health inequalities are so deeply entrenched that providing disadvantaged groups or areas with better services – and better access to those services – can only be one element of a broader strategy to address the distribution of the wider determinants of health. All activities need to be developed and sustained on a long-term basis.

Pregnant women

Helping pregnant women who smoke to quit involves communicating in a sensitive, client-centred manner, particularly as some pregnant women find it difficult to say that they smoke. Such an approach is important to reduce the likelihood that some of them may miss out on the opportunity to get help.

Mass-media and point-of-sale measures

Mass-media and point-of-sales measures should be combined with other prevention activities as part of a comprehensive tobacco control strategy. Such a strategy is defined by the US Surgeon General, World Health Organization and others as encompassing price and regulation policies, education programmes, cessation support services and community programmes. It should be sufficiently extensive and sustained to have a reasonable chance of success.

Workplace interventions

Reducing smoking and tobacco-related harm is a key government strategy for improving the health of people in England and reducing health inequalities. Since July 2007, smoking has been prohibited in virtually all enclosed public places and workplaces in England. This includes vehicles used for business and any rooms or shelters previously set aside for smoking (if they are enclosed or substantially enclosed, according to the definition of the law). Failure to comply is an offence.
Employers are not legally obliged to help employees to stop smoking. However, those that do provide cessation support could reduce the risk of non-compliance with the law, as well as taking advantage of the opportunity it offers to improve people's health. They will be promoting healthy living and no smoking within society, as well as benefiting from reduced sickness absence and increased productivity.

Adults who are disadvantaged and at high risk of dying from cardiovascular disease or other smoking-related diseases

High risk of cardiovascular disease (CVD)

According to NICE guidance, if someone has a 20% or higher risk of a first cardiovascular event in the next 10 years they are deemed at high risk of CVD.

Smoking cessation and statins

Statin provision and smoking cessation services were used as the basis of the recommendations on reducing the rate of premature deaths from cardiovascular disease and other smoking-related diseases because:
  • Methods of identifying and supporting adults and improving their access to services need to be assessed using interventions which have already been established as effective and cost effective. Smoking cessation services and the provision of statins are both generally agreed to be effective and cost effective.
  • Epidemiological data show a clear socioeconomic gradient for smoking and CVD. Tackling smoking and providing statins, as recommended, should make a significant contribution to reducing health inequalities.

Cost effectiveness

It is cost effective to identify adults in secondary care who are disadvantaged and need statins (and then prescribe these drugs). In primary care, the cost effectiveness of identifying people at risk of CVD and providing them with statins is determined by the number at risk of CVD in the baseline population. (The more people at risk, the more cost effective it becomes to identify them and provide them with statins.)

Implementation

The recommendations focus on system and structural changes to ensure effective clinical and public health practice can take place. This requires a comprehensive approach at all levels of the health system (for example, involving both practitioners and commissioners) and in partnership with others in the wider public, community and voluntary sectors.
Effective implementation will require:
  • an appropriate infrastructure and resources for commissioners, planners and service providers
  • policy initiatives which prioritise health inequalities and ensure action to tackle them are included in PCT plans and local area agreements.

Updates to this pathway

5 June 2013 Added link to the Smoking: tobacco-harm reduction approaches pathway to the overview and general minor maintenance update.
26 September 2012 Added link to the Smokeless tobacco cessation: South Asian communities pathway to the overview.
14 May 2012 Effective interventions library information added to system incentives to improve the health of people who are disadvantaged and primary care health practitioners.
31 January 2012 Clarification of when to use a CO breath test added to referring women from maternity services to evidence-based stop smoking services.
25 October 2011 Minor maintenance updates

Supporting information

Glossary

Brief interventions (also known as brief advice) to help people stop smoking involve opportunistic advice, discussion, negotiation or encouragement and, where necessary, referral to more intensive treatment. They are delivered by a range of professionals, typically in less than 10 minutes.
The package provided depends on a number of factors including someone's willingness to quit, how acceptable they find the intervention and previous methods they have used. It may include one or more of the following:
  • simple opportunistic advice
  • an assessment of the person's commitment to quit
  • pharmacotherapy and/or behavioural support
  • self-help material
  • referral to more intensive support such as evidence-based stop smoking services.
Cardiovascular disease (CVD) is generally due to reduced blood flow to the heart, brain or body caused by atheroma or thrombosis. Plaques (plates) of fatty atheroma build up in different arteries during adult life. These can eventually cause narrowing of the arteries, or trigger a local thrombosis (blood clot) which completely blocks the blood flow. The main types of CVD are: coronary heart disease (CHD), stroke and peripheral arterial disease (PVD).
Source: What is cardiovascular disease? What is coronary heart disease? What is stroke?
Adults who are disadvantaged include (but are not limited to):
  • those on a low income (or who are members of a low-income family)
  • those on benefits
  • those living in public or social housing
  • some members of black and minority ethnic groups
  • those with a mental health problem
  • those with a learning disability
  • those who are institutionalised (including those serving a custodial sentence)
  • those who are homeless.
Local agencies define disadvantaged areas in a variety of ways. An example is the 'Index of Multiple Deprivation 2007'. This combines indicators on economic, social and housing issues to produce a single deprivation score.
Local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. The professionals involved may include midwives who have been specially trained to help pregnant women who smoke to quit.
Group behaviour therapy programmes involve weekly meetings for the first 4 weeks of a quit attempt. During these meetings, people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy) delivered over at least two sessions. See 'Individual behavioural counselling for smoking cessation'.
This is a face-to-face encounter between someone who smokes and a counsellor trained in smoking cessation.
Mass-media interventions use a range of methods to communicate a message. This can include local, regional or national television, radio and newspapers, and leaflets and booklets. It can also include new media.
In this pathway, 'new media' refers to communication via the Internet or mobile phone.
On the Internet, it can involve anything from real-time streaming of information and podcasts, to discussions with experts and the use of social networking sites. (An example of real-time streaming of information is the 'breaking news' text that appears along the bottom of the screen during some TV news programmes.)
The aim of mass-media interventions is to reach large numbers of people without being reliant on face-to-face contact.
Stop smoking advisers and healthcare professionals may recommend and prescribe nicotine replacement therapy (NRT), varenicline or bupropion as an aid to help people to quit smoking, along with giving advice, encouragement and support.
Before prescribing a treatment, they take into account the person's intention and motivation to quit and how likely it is they will follow the course of treatment. They also consider which treatments the individual prefers, whether they have attempted to stop before (and how), and if there are medical reasons why they should not be prescribed NRT, varenicline or bupropion.
Point-of-sales interventions take place at the point where tobacco could be sold. Primarily, they aim to deter shopkeepers from making illegal sales.
In this pathway 'Schools' is used to refer to the following educational establishments:
  • maintained and independent primary, secondary and special schools
  • city technology colleges and academies
  • pupil referral units, secure training and local authority secure units
  • further education colleges
  • 'extended schools' where childcare or informal education is provided outside school hours.
Self-help materials comprise any manual or structured programme, in written or electronic format, that can be used by individuals in a quit attempt without the help of health professionals, counsellors or group support. Materials can be aimed at anyone who smokes, particular populations (for example, certain age or ethnic groups) or may be interactively tailored to individual need. See Self-help interventions for smoking cessation.
Telephone counselling and quitlines provide proactive or reactive advice, encouragement and support over the telephone to anyone who smokes who wants to quit, or who has recently quit.
Confidence interval. There is always some uncertainty in research. This is because a small group of people is studied to predict the effects of an intervention on the wider population. The confidence interval is a way of expressing how certain we are about the findings from a study, using statistics. It gives a range of results that is likely to include the 'true' value for the population.
The CI is usually stated as '95% CI', which means that the range of values has a 95 in a 100 chance of including the 'true' value. For example, a study may state that 'based on our sample findings, we are 95% certain that the 'true' population blood pressure is not higher than 150 and not lower than 110'. In such a case the 95% CI would be 110 to 150.
A wide confidence interval indicates a lack of certainty about the true effect of the test or treatment – often because a small group of patients has been studied. A narrow confidence interval indicates a more precise estimate (for example, if a large number of patients have been studied).
Effect size. A measure that shows the magnitude of the outcome in one group compared with that in a control group.
For example, if the absolute risk reduction is shown to be 5% and it is the outcome of interest, the effect size is 5%.
The effect size is usually tested, using statistics, to find out how likely it is that the effect is a result of the treatment and has not just happened by chance (that is, to see if it is statistically significant).
NICE analysts have calculated this figure using data from the original study.
Incremental cost effectiveness ratio. A measure of the cost effectiveness of a treatment or health intervention. It estimates how much more the benefits of a certain treatment cost, compared with other treatments or health interventions.
Number needed to treat. The average number of people who need to receive an intervention to get a positive outcome. For example, if the NNT is four, then 4 people would have to receive the intervention to ensure one of them gets better. The closer the NNT is to one, the better the intervention. However, as with most data, caution is needed when considering whether results apply to populations beyond the sample described in the original study.
Odds ratio. Odds are a way to represent how likely it is that something will happen (the probability). An odds ratio compares the probability of something in one group with the probability of the same thing in another.
An odds ratio of 1 between two groups would show that the probability of the event (for example a person developing a disease, or an intervention working) is the same for both.
Sometimes probability can be compared across more than two groups – in this case, one of the groups is chosen as the 'reference category', and the odds ratio is calculated for each group compared with the reference category. For example, to compare the risk of dying from lung cancer for non-smokers, occasional smokers and regular smokers, non-smokers could be used as the reference category. Odds ratios would be worked out for occasional smokers compared with non-smokers and for regular smokers compared with non-smokers.
Quality-adjusted life year. A measure of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life. One QALY is equal to 1 year of life in perfect health.
QALYS are calculated by estimating the years of life remaining for a person following a particular treatment or intervention and weighting each year with a quality of life score (on a zero to one scale). It is often measured in terms of the person's ability to perform the activities of daily life, freedom from pain and mental disturbance.
Randomised controlled trial. A study in which a number of similar people are randomly assigned to two (or more) groups to test a specific drug or intervention. One group (the experimental group) receives the intervention being tested, the other (the comparison or control group) receives an alternative intervention, a dummy intervention (placebo) or no intervention at all. The groups are followed up to see how effective the experimental intervention was. Outcomes are measured at specific times and any difference in response between the groups is assessed statistically. This method is also used to reduce bias.
Standard deviation. A measure used to summarise numerical data and describe how 'spread out' a set of measures (or 'values') are from the average. For example, the average height of a group of schoolchildren can be calculated using the total of all their heights added together and then divided by the number of schoolchildren in the group. Standard deviation measures the 'spread' of those heights. So, in the example it tells you whether all those in the group were about the same height or whether some were very tall and some were short.

Community, voluntary, independent and business

Recommendations for community groups and the voluntary, independent and business sectors

Organisations working with people who smoke

Community organisations working with people who smoke

Community organisations working with people who smoke

Referral

Community workers should refer people who smoke to an intensive support service (an evidence-based stop smoking service). Those who are trained stop smoking counsellors may 'refer' to themselves.

Smoking cessation policies

NHS hospital trusts, commissioners of public health services, community pharmacies, local authorities and local community groups should review smoking cessation policies and practices to take account of the recommendations in this guidance.

Source guidance

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PH1

Organisations that work with pregnant women

Organisations working with women before, during and after pregnancy

Organisations working with women before, during and after pregnancy

Referring pregnant women who smoke to evidence-based stop smoking servicesThis recommendation is from Quitting smoking in pregnancy and following childbirth (NICE public health guidance 26)

Who should take action?

Those responsible for providing health and support services for the target group of women. This does not include midwives, see community health services for women, including teenage girls, who are pregnant or who are planning a pregnancy. It does include:
  • those working in youth and teenage pregnancy services, children's centres and social services
  • those working in fertility clinics, dental practices, community pharmacies and voluntary and community organisations
  • GPs, practice nurses, health visitors and family nurses
  • obstetricians, paediatricians, sonographers and other members of the maternity team (apart from midwives)

What action should they take?

Use any appointment or meeting as an opportunity to ask women if they smoke. If they do, explain how evidence-based stop smoking services can help people to quit and advise them to stop.
Offer those who want to stop a referral to evidence-based stop smoking services.
Use local arrangements to make a referral. Record this in the hand-held record. If a hand-held record is not available locally, use local protocols to record this information.
Give the NHS Pregnancy Smoking Helpline number in case they want to talk to someone over the phone in the meantime: 0800 1699 169. Also provide the local helpline number where one is available.
Those with specialist training should provide pregnant women who smoke with information (for example, a leaflet) about the risks to the unborn child of smoking when pregnant. They should also provide information on the hazards of exposure to secondhand smoke for both mother and baby and on the benefits of stopping smoking. Information should be available in a variety of formats.

Ongoing support for women who are pregnant or planning a pregnancyThis recommendation is from Smoking cessation services (NICE public health guidance 10).

Who should take action?

All those responsible for providing health and support services for pregnant women, for those wishing to become pregnant, and for their partners. This includes: those working in fertility clinics, midwives, GPs, dentists, hospital and community pharmacists, and those working in children's centres, voluntary organisations and occupational health services.

What action should they take?

At the first contact with the woman, discuss her smoking status, provide information about the risks of smoking to the unborn child and the hazards of exposure to secondhand smoke. Address any concerns she and her partner or family may have about stopping smoking.
Offer personalised information, advice and support on how to stop smoking. Encourage pregnant women to use local evidence-based stop smoking services and the NHS Pregnancy Smoking Helpline by providing details on when, where and how to access them. Consider visiting pregnant women at home if it is difficult for them to attend specialist services.
Monitor smoking status and offer smoking cessation advice, encouragement and support throughout the pregnancy and beyond.
Discuss the risks and benefits of NRT with pregnant women who smoke, particularly those who do not wish to accept the offer of help from the evidence-based stop smoking service. If a woman expresses a clear wish to receive NRT, use professional judgement when deciding whether to offer a prescription.
Advise pregnant women using nicotine patches to remove them before going to bed.

Implementation tools

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Quitting smoking in pregnancy and following childbirth: self-assessment tool
Smoking cessation: online educational tool
Quitting smoking in pregnancy and following childbirth: slide set

Source guidance

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PH26
PH10

Partnership working

Partnership working between the voluntary and business sectors, criminal justice system and commissioners of public health services

Partnership working between the voluntary and business sectors, criminal justice system and commissioners of public health services

Whose health will benefit?

Adults who are disadvantaged:
  • who smoke and/or
  • who are eligible for statins and/or
  • who are at high risk of CVD due to other factors.

Who should take action?

Planners, commissioners and service providers with a remit for tackling health inequalities. This includes commissioners of public health services, general practices, community services, local partnerships, local authorities (including education and social services), the criminal justice system and members of the voluntary and business sectors.

What action should they take?

Develop and sustain partnerships with professionals and community workers who are in contact with people who are disadvantaged. Use joint strategic needs assessments, local partnerships, the GP contract and other mechanisms. For recommendations on community engagement see community engagement.
Establish relationships between primary care practitioners and the community to understand how best to identify and help adults who are disadvantaged to adopt healthier lifestyles. For example, they should jointly determine how best to support health initiatives delivered as part of a local strategy.
Establish relationships with secondary care professionals (for example, those working in respiratory medicine and CVD clinics) to help identify patients at high risk of further cardiovascular events. Offer these patients support or refer them on, where appropriate.
Develop and maintain a database of local initiatives that aim to reduce health inequalities by improving the health of people who are disadvantaged.
Develop and sustain local and national networks for sharing local experiences. Ensure mechanisms are in place to evaluate and learn from these activities on a continuing, systematic basis.
Ensure those working in the healthcare, community and voluntary sectors coordinate their efforts to identify people who need help.

Source guidance

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PH15

Local tobacco alliances

Local tobacco alliances

General campaigns

View the 'General' node

Coordinated approach in education

View the 'Coordinated approach' node

Mass media campaigns

View the 'Mass media' node

Paths in this pathway

Pathway created: May 2011 Last updated: June 2013

Copyright © 2013 National Institute for Health and Care Excellence. All Rights Reserved.



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