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Support from general NHS services to help people stop smoking

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Smoking

About

What is covered

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.

Updates

Updates to this pathway

6 August 2015 Updates to smoking cessation: supporting people to stop smoking (NICE quality standard 43).
22 June 2015 Antenatal care quality standard updated.
31 March 2015 Minor maintenance update.
24 March 2015 Smoking: reducing tobacco use (NICE quality standard 82) added to this pathway.
7 November 2014 Amendments made to illegal sales and trading standards due to updated guidance to reflect the ban on the sale of tobacco from vending machines, which came into effect in October 2011 in England.
18 August 2014 Minor maintenance update.
11 August 2014 Links to NICE pathways on smoking cessation and secondary care; tobacco harm reduction approaches and smokeless tobacco cessation in South Asian communities added.
17 July 2014 Link to NICE pathway on cardiovascular disease prevention added.
2 January 2014 Minor maintenance update.
27 August 2013 Antenatal care quality standard (QS22) and Smoking cessation quality standard (QS43) added.
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

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.

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.

What is covered

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.

Updates

Updates to this pathway

6 August 2015 Updates to smoking cessation: supporting people to stop smoking (NICE quality standard 43).
22 June 2015 Antenatal care quality standard updated.
31 March 2015 Minor maintenance update.
24 March 2015 Smoking: reducing tobacco use (NICE quality standard 82) added to this pathway.
7 November 2014 Amendments made to illegal sales and trading standards due to updated guidance to reflect the ban on the sale of tobacco from vending machines, which came into effect in October 2011 in England.
18 August 2014 Minor maintenance update.
11 August 2014 Links to NICE pathways on smoking cessation and secondary care; tobacco harm reduction approaches and smokeless tobacco cessation in South Asian communities added.
17 July 2014 Link to NICE pathway on cardiovascular disease prevention added.
2 January 2014 Minor maintenance update.
27 August 2013 Antenatal care quality standard (QS22) and Smoking cessation quality standard (QS43) added.
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

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Smoking cessation services (2008) NICE guideline PH10
Varenicline for smoking cessation (2007) NICE technology appraisal guidance 123

Quality standards

Smoking cessation quality standard

These quality statements are taken from the smoking cessation: supporting people to stop smoking quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statements

Identifying people who smoke

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People are asked if they smoke by their healthcare practitioner, and those who smoke are offered advice on how to stop.

Rationale

There is evidence that people who smoke are receptive to smoking cessation advice in all healthcare settings. It is therefore important that healthcare practitioners proactively ask people if they smoke, and offer advice on how to stop.

Quality measures

Structure
Evidence of local arrangements to ensure that people are asked if they smoke by their healthcare practitioner, and those who smoke are offered advice on how to stop.
Data source: Local data collection.
Process
a) Proportion of people who are asked if they smoke by their healthcare practitioner.
Numerator – the number of people in the denominator who are asked if they smoke by their healthcare practitioner.
Denominator – the number of people who have face-to-face contact with a healthcare practitioner.
Data source: a) Local data collection. The quality and outcomes framework (QOF) contains indicators related to identifying and supporting people who smoke in primary care.
b) Proportion of people who smoke who receive advice on how to stop.
Numerator – the number of people in the denominator who receive advice on how to stop.
Denominator – the number of people who report that they smoke during face-to-face contact with a healthcare practitioner.
Data source: b) Local data collection. NICE public health guidance 10: audit support – criterion 3i. The QOF contains indicators related to identifying and supporting people who smoke in primary care.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people to be asked if they smoke by their healthcare practitioner, and for those who smoke to be offered advice on how to stop.
Healthcare practitioners ask their patients if they smoke, and offer those who smoke advice on how to stop.
Commissioners ensure that they commission services where healthcare practitioners ask their patients if they smoke, and that they offer those who smoke advice on how to stop.

What the quality statement means for patients, service users and carers

People are asked if they smoke by their healthcare practitioners, and those who smoke are offered advice on how to stop.

Source guidance

Definition of terms used in this quality statement

Healthcare practitioners include, but are not limited to, doctors, nurses, midwives, pharmacists, dentists, opticians and allied health professionals.
Advice can vary by healthcare setting. In the context of primary care settings, this would involve evidence-based, opportunistic advice offered to people who smoke about the options and support available to help them stop smoking. In the context of secondary care settings, advice may involve the practitioner providing people who smoke with information and referring them to an evidence-based smoking cessation service.
The National Centre for Smoking Cessation and Training offers a training module on the delivery of evidence-based smoking cessation interventions, to ensure that this is done in a sensitive way within the brief time available with the patient.
This statement is linked to statement 2, because advice on how to stop may include a referral to an evidence-based smoking cessation service.

Equality and diversity considerations

Advice should be culturally appropriate and accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.
Advice may include referral to an evidence-based smoking cessation service. NICE public health guidance 10 states that such services should target minority ethnic and socioeconomically disadvantaged communities in the local population; it is important to ensure that services are easily accessible by people from these groups and that they are encouraged to use them.
Lesbian, gay, bisexual and transgender (LGBT) groups have higher smoking prevalence rates than the general population, and as such, services should be accessible and commissioned to address this need.
Healthcare practitioners should be sensitive to the issue of smoking in young people. NICE guidance recommends that young people aged 12–17 who smoke should be offered information, advice and support on how to stop smoking and be encouraged to use local evidence-based smoking cessation services.
Practitioners should be aware that some pregnant women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.

Referral to smoking cessation services

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who smoke are offered a referral to an evidence-based smoking cessation service.

Rationale

Smoking cessation services provide the most effective route to stopping smoking, but many people who smoke do not use these services when they try to stop. It is therefore important that practitioners are aware of and make use of the opportunities to refer people who smoke to an evidence-based smoking cessation service.
Quality statement 5 in the NICE quality standard on antenatal care sets out the high-quality requirements for ensuring that pregnant women who smoke are referred to an evidence-based smoking cessation service.

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke are offered a referral to an evidence-based smoking cessation service.
Data source: Local data collection.
Process
Proportion of people who smoke who are referred to an evidence-based smoking cessation service.
Numerator – the number of people in the denominator who are referred to an evidence-based smoking cessation service.
Denominator – the number of people identified as smokers in any healthcare setting.
Data source: Local data collection. The quality and outcomes framework (QOF) contains indicators related to support in primary care for people who smoke.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people who smoke to be offered a referral to an evidence-based smoking cessation service.
Healthcare practitioners offer people who smoke a referral to an evidence-based smoking cessation service.
Commissioners ensure that they commission services that offer people who smoke a referral to an evidence-based smoking cessation service.

What the quality statement means for patients, service users and carers

People who smoke are offered a referral to an evidence-based smoking cessation service to help them stop smoking.

Source guidance

Definition of terms used in this quality statement

Healthcare practitioners include, but are not limited to, doctors, nurses, midwives, pharmacists, dentists, opticians and allied health professionals.
Evidence-based smoking cessation services are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. NICE public health guidance 10 describes key characteristics of an evidence-based smoking cessation service. These include addressing the needs of minority communities in the local population, maintaining adequate staffing levels and benchmarking and reporting service outcomes.
The National Centre for Smoking Cessation and Training offers training modules for people delivering smoking cessation interventions.
This statement is linked to statement 1, because advice on how to stop may include a referral to an evidence-based smoking cessation service.
Quality statement 5 in the NICE quality standard on antenatal care states that 'Pregnant women who smoke are referred to an evidence-based stop smoking service at the booking appointment' and the appropriate referral criteria are defined. The supporting information also states that the midwife may provide the pregnant woman with information (in a variety of formats, for example, a leaflet) about the risks to the unborn child of smoking when pregnant and the hazards of exposure to secondhand smoke for both mother and baby.

Equality and diversity considerations

NICE public health guidance 10 states that evidence-based smoking cessation services should target minority ethnic and socioeconomically disadvantaged communities in the local population; it is important to ensure that services are easily accessible by people from these groups and that they are encouraged to use them.
Lesbian, gay, bisexual and transgender (LGBT) groups have higher smoking prevalence rates than the general population, and as such, services should be accessible and commissioned to address this need.
Healthcare practitioners should be sensitive to the issue of smoking in young people. NICE guidance recommends that young people aged 12–17 who smoke should be offered information, advice and support on how to stop smoking and be encouraged to use evidence-based smoking cessation services.
Practitioners should be aware that some pregnant women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.

Behavioural support with pharmacotherapy

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who smoke are offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service.

Rationale

People who smoke are more likely to stop smoking if they are offered a combination of interventions, with combined behavioural support and pharmacotherapy the most likely to be successful.

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke are offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service.
Data source: Local data collection.
Process
Proportion of people who receive behavioural support with pharmacotherapy from an evidence-based smoking cessation service.
Numerator – the number of people in the denominator who receive behavioural support with pharmacotherapy from an evidence-based smoking cessation service.
Denominator – the number of people referred to an evidence-based smoking cessation service.
Data source: Local data collection. Contained in NICE public health guidance 10: audit support – criterion 7; Statistics on NHS Stop Smoking Services: England, April 2011 – March 2012 from the Health and Social Care Information Centre reports on smoking cessation interventions.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people who smoke to be offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service.
Healthcare practitioners offer behavioural support with pharmacotherapy to people who have been referred to an evidence-based smoking cessation service.
Commissioners ensure that they commission evidence-based smoking cessation services that offer people who smoke behavioural support with pharmacotherapy.

What the quality statement means for patients, service users and carers

People who have been referred to an evidence-based smoking cessation service are offered behavioural support (which may be either individual or group counselling) together with drug treatment.

Source guidance

Definition of terms used in this quality statement

Behavioural support
This can be individual behavioural therapy or group behaviour therapy.
NICE public health guidance 10 states that individual behavioural therapy involves scheduled face-to-face meetings between someone who smokes and a practitioner from the smoking cessation service trained in smoking cessation. Typically, it involves weekly sessions over a period of at least 4 weeks after the quit date and is normally combined with pharmacotherapy.
NICE public health guidance 10 states that group behaviour therapy involves scheduled meetings where people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy). This therapy is offered weekly for at least the first 4 weeks of a quit attempt (that is, for 4 weeks following the quit date). It is normally combined with pharmacotherapy.
Pharmacotherapy
Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion.
NICE public health guidance 10 states that neither varenicline nor bupropion should be offered to young people under 18. Professional judgement should be used to decide whether or not to offer NRT to young people over 12 years who show clear evidence of nicotine dependence. If NRT is prescribed, offer it as part of a supervised regime. Varenicline or bupropion may be offered to people with unstable cardiovascular disorders who smoke, subject to clinical judgement.
NICE public health guidance 26 states that there should be a discussion about the risks and benefits of NRT with pregnant women who smoke. Nicotine replacement therapy should be offered if smoking cessation without NRT fails, or practitioner judgement should be used if women express a clear preference for NRT. Neither varenicline nor bupropion should be offered to pregnant or breastfeeding women.
A summary of further considerations relating to pharmacotherapy is provided in quality statement 4.
Evidence-based stop smoking services
These are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. NICE public health guidance 10 describes key characteristics of an evidence-based smoking cessation service. These include addressing the needs of minority communities in the local population, maintaining adequate staffing levels and benchmarking and reporting service outcomes.

Pharmacotherapy

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course.

Rationale

Pharmacotherapy interventions act as an aid to help people to stop smoking, and it is important that people who seek support to stop smoking receive the full course of their chosen pharmacotherapy to increase the chances of success.

Quality measures

Structure
Evidence of local arrangements to ensure that people who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course.
Data source: Local data collection.
Process
Proportion of people who seek support to stop smoking and who agree to take pharmacotherapy who receive a full course.
Numerator – the number of people in the denominator who receive a full course of pharmacotherapy.
Denominator – the number of people who seek support to stop smoking and who agree to take pharmacotherapy.
Data source: Local data collection. Contained in NICE public health guidance 1: audit – criterion 5 and NICE public health guidance 10: audit support – criteria 5–8; Statistics on NHS Stop Smoking Services: England, April 2011 – March 2012 from the Health and Social Care Information Centre reports on smoking cessation interventions.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place so that people who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course.
Healthcare practitioners offer a full course of pharmacotherapy to people who seek support to stop smoking and who agree to take pharmacotherapy.
Commissioners ensure that they commission services that offer a full course of pharmacotherapy to people who seek support to stop smoking and who agree to take pharmacotherapy.

What the quality statement means for patients, service users and carers

People who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course of drug treatment.

Source guidance

Definition of terms used in this quality statement

Pharmacotherapy
Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion.
NICE public health guidance 10 states that healthcare professionals who prescribe nicotine replacement therapy (NRT), varenicline or bupropion should offer advice, encouragement and support including referral to an evidence-based smoking cessation service. Pharmacotherapy should normally be prescribed as part of an abstinent contingent treatment, in which the smoker makes a commitment to stop smoking on or before a particular date. NICE technology appraisal guidance 123 states that varenicline should normally be prescribed only as part of a programme of behavioural support.
NICE public health guidance 10 states that neither varenicline nor bupropion should be offered to young people under 18. Professional judgement should be used to decide whether or not to offer NRT to young people over 12 years who show clear evidence of nicotine dependence. If NRT is prescribed, offer it as part of a supervised regime. Varenicline or bupropion may be offered to people with unstable cardiovascular disorders who smoke, subject to clinical judgement.
NICE public health guidance 26 states that there should be a discussion about the risks and benefits of NRT with pregnant women who smoke. Nicotine replacement therapy should be offered if smoking cessation without NRT fails, or practitioner judgement should be used if women express a clear preference for NRT. Neither varenicline nor bupropion should be offered to pregnant or breastfeeding women.
It is important that people who smoke who receive pharmacotherapy receive a full course, which will vary depending on the individual smoker. A full course for NRT is at least 8 weeks, for varenicline it is at least 12 weeks and for bupropion it is at least 8 weeks. NICE public health guidance 10 outlines that the prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date with subsequent prescriptions given only to people who have demonstrated, on re-assessment, that their quit attempt is continuing.
Drugs with a metabolism that is affected by smoking (or stopping smoking) should be monitored, and the dosage adjusted if appropriate.

Equality and diversity considerations

There should be a discussion about risks and benefits of using NRT with young people aged 12–17 and pregnant or breastfeeding women.

Outcome measurement

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.

Rationale

Recording smoking status using carbon monoxide testing after 4 weeks provides an incentive for people who are attempting to stop, and is an objective way to measure individual and service level outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Data source: Local data collection.
Process
Proportion of people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Numerator – the number of people in the denominator who are assessed for carbon monoxide levels 4 weeks after the quit date.
Denominator – the number of people who smoke who have set a quit date with an evidence-based smoking cessation service.
Data source: Local data collection. The Health and Social Care Information Centre's Indicator Portal collects data on the number of people who smoke who successfully quit at the 4-week follow-up per 100,000 population.
Outcome
4-week quit rates.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place so that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Healthcare practitioners ensure that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Commissioners ensure that they commission services for people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.

What the quality statement means for patients, service users and carers

People who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.

Source guidance

Definition of terms used in this quality statement

NICE public health guidance 10 states that success should be validated by a carbon monoxide monitor reading of less than 10 ppm at the 4-week point. This does not imply that treatment should stop at 4 weeks.
Evidence-based smoking cessation services
These are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. NICE public health guidance 10 describes key characteristics of an evidence-based smoking cessation service. These include addressing the needs of minority communities in the local population, maintaining adequate staffing levels and benchmarking and reporting service outcomes.

Schools and colleges: interventions

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Schools and colleges deliver combined interventions to stop children and young people taking up smoking by improving their social competence and awareness of social influences.

Rationale

Schools and colleges have an important role in helping children and young people to understand the harm associated with tobacco products. Most schools and colleges have already implemented smokefree policies, and teaching about tobacco use and its impact is part of the curriculum. However, children and young people still face substantial pressures to start smoking from their peers, family members, the media and the tobacco industry. Combined interventions to improve social competence and to make students aware of the social influences that support smoking are effective in preventing children and young people from taking up smoking.

Quality measures

Structure
Evidence of arrangements within local schools and colleges to deliver combined interventions to stop children and young people taking up smoking by improving their social competence and awareness of social influences.
Data source: Local data collection.
Process
a) Proportion of schools and colleges that deliver combined interventions to stop children and young people taking up smoking by improving their social competence and awareness of social influences.
Numerator – the number in the denominator that deliver combined interventions to stop children and young people taking up smoking by improving their social competence and awareness of social influences.
Denominator – the number of schools and colleges in a specified geographic area.
Data source: Local data collection.
b) Proportion of children and young people who receive combined interventions to stop them taking up smoking by improving their social competence and awareness of social influences.
Numerator – the number in the denominator who receive combined interventions to stop them taking up smoking by improving their social competence and awareness of social influences.
Denominator – the number of children and young people in schools and colleges in a specified geographic area.
Data source: Local data collection.
Outcome
Proportion of children and young people who have tried smoking at least once.
Data source: Statistics on smoking, England 2014 covers the national prevalence of smoking among young people aged 16–19 and secondary school students (mostly aged 11–15).

What the quality statement means for schools and colleges

Schools and colleges deliver combined interventions to stop children and young people taking up smoking by improving their social competence and awareness of social influences.

What the quality statement means for children and young people

Children and young people take part in programmes at their school or college that help them to refuse offers of tobacco products by improving their self esteem, how they cope with stress, and general social and assertive skills.

Source guidance

Definitions of terms used in this quality statement

Schools and colleges
In this quality standard schools and colleges include:
  • 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. [NICE guideline PH23]
Social competence interventions
A group of interventions that aim to help children and young people refuse offers to smoke by improving their general social competence. Programmes benefit from including social learning processes or life skills such as:
  • problem solving and decision making
  • cognitive skills for resisting interpersonal or media influences
  • increased self control and self esteem
  • coping strategies for stress
  • general social and assertive skills.
These interventions can be peer led or adult led and can have tobacco products as a focus or be more general.
[Cochrane review and expert opinion]
Social influences interventions
Interventions that aim to increase awareness of social influences that promote tobacco use and help students overcome these influences. Programmes adopt resistance skills training in which students are taught how to:
  • deal with peer pressure
  • deal with high risk situations
  • effectively refuse direct and indirect attempts to persuade them to use tobacco products.
[Cochrane review and expert opinion]

Equality and diversity considerations

Smoking rates are higher among those excluded from school and they will not be able to benefit from these interventions. Other activities carried out locally should address the needs of this group.

Schools and colleges: smokefree grounds

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Schools and colleges do not allow smoking anywhere in their grounds and remove any areas previously designated for smoking.

Rationale

Most schools and colleges already have a smokefree policy in place, which includes having smokefree grounds. However, some of the smokefree grounds still allow smoking in designated smoking areas and may even provide smoking shelters. Allowing anyone to smoke anywhere in the school grounds at any time, makes it seem an acceptable activity. Providing outdoor smoking areas facilitates smoking.

Quality measures

Structure
Evidence of arrangements in local schools and colleges to operate smokefree grounds and remove any areas designated for smoking.
Data source: Local data collection.
Process
a) Proportion of schools and colleges that do not allow smoking anywhere in the grounds.
Numerator – The number in the denominator that do not allow smoking anywhere in the grounds.
Denominator – The number of schools and colleges in the specified geographic area.
Data source: Local data collection.
b) Proportion of schools and colleges with no designated areas for smoking.
Numerator – The number in the denominator with no designated areas for smoking.
Denominator – The number of schools and colleges in the specified geographic area.
Data source: Local data collection.
Outcome
Schools and colleges with smokefree grounds and no areas designated for smoking.
Data source: Local data collection.

What the quality statement means for schools and colleges

Schools and colleges ensure that smoking is not allowed anywhere in the grounds and that the smokefree policy applies to anyone using the premises for any purpose at any time. They should also remove any existing areas previously designated for smoking in the grounds.

What the quality statement means for children and young people

Children and young people attend schools and colleges that do not allow smoking anywhere in the school or the school grounds at any time. The schools and colleges do not have any areas in the grounds set aside for smoking.

Source guidance

Definitions of terms used in this quality statement

Schools and colleges
In this quality standard schools and colleges include:
  • 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. [NICE guideline PH23]

Equality and diversity considerations

Smoking rates are higher among those excluded from school and they will not be able to benefit from these actions. Other activities carried out locally should address the needs of this group.

Underage sales

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Trading standards identify and take action against retailers that sell tobacco products to people under 18.

Rationale

It is illegal to sell tobacco products to anyone under 18. Trading standards should work in partnership with retailers, police and the wider community to gather reliable information and take action against local retailers who sell tobacco to people under 18. This may include providing advice and guidance to the retailers, test purchasing and taking legal action.

Quality measures

Structure
a) Evidence of local arrangements to obtain and interpret information to identify retailers that sell tobacco products to people under 18.
Data source: Local data collection.
b) Evidence of local actions undertaken to prevent retailers from selling tobacco products to people under 18.
Data source: Local data collection.
Process
a) Proportion of tobacco test purchases with a recorded underage sale.
Numerator – The number in the denominator with a recorded underage sale.
Denominator – The number of tobacco test purchases carried out in a specified geographic area.
Data source: Tobacco Control Survey, England. Trading Standards Institute.
b) Proportion of retailers with a recorded underage sale followed up with advice to the retailer.
Numerator – The number in the denominator followed up with advice to the retailer.
Denominator – The number of test purchases with a recorded underage sale in a specified geographic area.
Data source: Tobacco Control Survey, England. Trading Standards Institute.
c) Proportion of individuals sanctioned for persistently selling tobacco to people under 18.
Numerator – The number in the denominator sanctioned for persistently selling tobacco to people under 18.
Denominator – The number of individuals identified as persistently selling tobacco to people under 18 in a specified geographic area.
Data source: Tobacco Control Survey, England. Trading Standards Institute.
d) Proportion of tobacco sales outlets sanctioned for persistently selling tobacco to people under 18.
Numerator – The number in the denominator sanctioned for persistently selling tobacco to people under 18.
Denominator – The number of tobacco sales outlets identified as persistently selling tobacco to people under 18 in a specified geographic area.
Data source: Tobacco Control Survey, England. Trading Standards Institute.
Outcome
Incidence of underage tobacco sales.
Data source: Local data collection.

What the quality statement means for local trading standards and local retailers

Local trading standards work in partnership with retailers, the police and the wider community to gather reliable information and take action against local retailers who sell tobacco to people under 18.
Local retailers are subject to test purchase operations and if underage tobacco sales are recorded, further action is taken. They work with local trading standards in order to comply with the legislation. If the retailers are found persistently selling tobacco products to people under 18, they can be sanctioned by magistrate’ courts.

What the quality statement means for children and young people

Children and young people find it hard to buy tobacco products and hard to start or carry on smoking. This means that they are better protected from smoking related harm.

Source guidance

Definitions of terms used in this quality statement

Identifying retailers
Local trading standards, the police, HM Revenue and Customs, voluntary and community groups work in partnership to obtain, interpret and act on reliable intelligence to identify retailers that sell tobacco products to people under 18.
Trading standards also work with local retailers to increase awareness of, and compliance with, the tobacco legislation. [NICE guideline PH14 and expert opinion]
Taking actions against retailers
Actions taken against retailers include:
  • undertaking test purchases to detect breaches in the law at retailers identified by local intelligence
  • raising awareness of tobacco legislation among retailers and providing advice to those retailers found selling tobacco to anyone under 18
  • using sanctions and taking legal action against retailers.
Trading standards can apply to the magistrates’ court to impose fines or sanctions on the retailers. The maximum fine is £2500. When a person is convicted of making an illegal sale to anyone under 18 and, on at least 2 other occasions within a 2 year period, has committed other similar offences (these do not need to have resulted in a conviction), a sanction may be applied for. The magistrates’ court can issue a Restricted Premises Order or a Restricted Sale Order, or both.
Restricted Premises Order – The retail premises is prohibited from selling tobacco products for a period of up to 12 months.
Restricted Sale Order – A named person is prohibited from selling tobacco or managing premises in relation to the sale of tobacco products for a period of up to 12 months – the business may still sell tobacco but the individual may not. [Responsible tobacco retailing, 2014 and expert opinion]

Equality and diversity considerations

Smoking is more common in socially deprived areas and children and young people from poorer socioeconomic backgrounds take up smoking at an earlier age. Targeting retailers with awareness raising campaigns can potentially have more impact in disadvantaged areas.

Workplace policy

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Employers allow employees to access evidence based ‘stop smoking’ support during working hours without loss of pay.

Rationale

Many employers already have a policy outlining support to help employees to quit smoking. However, in practice, employees find it difficult to get time off to access ‘stop smoking’ services when needed. NHS and local authority employers should set an example in implementing this quality statement.
Evidence shows that people who smoke take an average of 30 minutes in cigarette breaks within business hours each day. A typical ‘stop smoking’ intervention lasts 30 minutes, once a week for the first 4 weeks after the quit attempt, then less frequently for a further 8 weeks. By enabling employees to access ‘stop smoking’ services, employers are likely to realise substantial benefits, such as increased productivity, decreased sickness rates and improved adherence to smokefree policies. More details about the economic gains for the employers can be found using the tobacco return on investment tool.

Quality measures

Structure
Evidence of HR policies that allow employees to access ‘stop smoking’ support during working hours without loss of pay.
Data source: Local data collection.
Process
a) Proportion of employees who wanted to access ‘stop smoking’ support during working hours and did so.
Numerator – The number in the denominator who accessed ‘stop smoking’ support during working hours.
Denominator – The number of employees who wanted to access ‘stop smoking’ support during working hours.
Data source: Local data collection.
b) Proportion of employees who accessed ‘stop smoking’ support during working hours without loss of pay.
Numerator – The number in the denominator who did not lose pay.
Denominator – The number of employees who accessed ‘stop smoking’ support during working hours.
Data source: Local data collection.

What the quality statement means for commissioners

Commissioners of ‘stop smoking’ services ensure that there is capacity within the ‘stop smoking’ services to deliver support to employers who want to help their employees to stop smoking.

What the quality statement means for employers and employees

All employers encourage employees who smoke (including students, apprentices and volunteers) to access ‘stop smoking’ support. They facilitate employees to access ‘stop smoking’ services by allowing them to attend during working hours without loss of pay. Employers may choose to organise on site ‘stop smoking’ services if that is feasible.
Employees who smoke can attend ‘stop smoking’ services during working hours, without losing pay.

What the quality statement means for managers of ‘stop smoking’ services

‘Stop smoking’ services proactively engage with local businesses by offering their support and promoting their services. In particular, they target businesses with high numbers of staff working in routine and manual jobs. This may mean that ‘stop smoking’ services are provided on site and there is increased demand on the service.

Source guidance

Definitions of terms used in this quality statement

Support offered by ‘stop smoking’ services
Support offered by ‘stop smoking’ services includes but is not limited to:
  • behavioural counselling, group therapy, pharmacotherapy or a combination of treatments that have been proven to be effective
  • tailored advice, counselling and support
  • pharmacotherapies – nicotine replacement therapy, varenicline or bupropion, as appropriate.
[Adapted from NICE guideline PH10, recommendations 2 and 4]

Equality and diversity considerations

Smoking is significantly more prevalent among people in routine and manual occupations. Targeting businesses that employ large numbers of people who work in routine and manual jobs has a potential to make a substantial difference.
Reducing smoking among people who are not employed is not specifically addressed by current guidelines, but smoking prevalence in this group is high. ‘Stop smoking’ services, Job Centre Plus and other organisations working with people who are unemployed have an opportunity to work together to enable people who are not employed to access ‘stop smoking’ services.

Healthcare services: employee contracts

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Healthcare services use contracts that do not allow employees to smoke during working hours or when recognisable as an employee.

Rationale

Healthcare services have a duty of care to protect the health of people who use or work in their services and to promote healthy behaviour among these groups. Healthcare services set an example to the wider community and ensure that ‘no smoking’ is the norm. Using contracts that do not allow employees (including contractors and volunteers) to smoke during working hours or when recognisable as an employee, reflects the services’ commitment to implementing and enforcing a smokefree policy.

Quality measures

Structure
Evidence of arrangements within healthcare services to use employee contracts (including contractor and volunteer contracts) that do not allow smoking during working hours or when recognisable as an employee.
Data source: Local data collection.
Process
Proportion of healthcare services that use employee contracts (including contractor and volunteer contracts) that do not allow smoking during working hours or when recognisable as an employee.
Numerator – The number in the denominator that use employee contracts (including contractor and volunteer contracts) that do not allow smoking during working hours or when recognisable as an employee.
Denominator – The number of healthcare services in the specified geographic area.
Data source: Local data collection.
Outcome
Staff, contractors and volunteers found smoking during working hours or when recognisable as an employee.
Data source: Local data collection.

What the quality statement means for directors and senior managers of healthcare services or their representatives, commissioners and people who work in healthcare services

Directors and senior managers of healthcare services or their representatives ensure that contracts that do not to allow smoking during working hours or when recognisable as an employee are used and enforced for all employees (including contractors and volunteers).
Commissioners ensure that they commission healthcare services that use and enforce employee contracts (including contractor and volunteer contracts) that do not allow smoking during working hours or when recognisable as an employee.
People who work in healthcare services (including contractors and volunteers) do not smoke during working hours or when recognisable as an employee as set out in their contracts.

What the quality statement means for patients and visitors

Patients and visitors of healthcare services are in a setting in which employees (including contractors and volunteers) do not smoke.

Source guidance

Definitions of terms used in this quality statement

Healthcare services
All publicly funded community, primary, secondary and tertiary healthcare services. [Adapted from NICE guideline PH48 and NICE guideline PH10]

Healthcare settings: smokefree grounds

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Healthcare settings do not allow smoking anywhere in their grounds and remove any areas previously designated for smoking.

Rationale

Healthcare services have a duty of care to protect the health of people who use or work in their services and to promote healthy behaviour among these groups. Healthcare settings set an example to the wider community and ensure that ‘no smoking’ is the norm. Many healthcare services already have a smokefree policy in place, which includes smokefree grounds. However, some still facilitate smoking in their grounds by providing outdoor smoking areas, such as smoking shelters or designated smoking points.

Quality measures

Structure
Evidence of arrangements within healthcare settings to operate smokefree grounds and remove any areas previously designated for smoking.
Data source: Local data collection.
Process
a) Proportion of healthcare settings that do not allow smoking anywhere in their grounds.
Numerator – The number in the denominator that do not allow smoking anywhere in their grounds.
Denominator – The number of healthcare settings in the specified geographic area.
Data source: Local data collection.
b) Proportion of healthcare settings with no designated smoking areas.
Numerator – The number in the denominator with no designated smoking areas.
Denominator – The number of healthcare settings in the specified geographic area.
Data source: Local data collection.

What the quality statement means for directors and senior managers of healthcare services or their representatives, commissioners and people who work in healthcare services

Directors and senior managers of healthcare settings or their representatives ensure that smoking is not allowed anywhere in the grounds of healthcare settings. They ensure that the smokefree policy applies to anyone using the premises for any purpose at any time. They should also remove any areas in the grounds previously designated for smoking.
Commissioners ensure that their contracts with healthcare services include smokefree grounds and removal of any existing areas designated for smoking in the grounds.
People who work in healthcare services (including contractors and volunteers) are not allowed to smoke anywhere in the grounds of their healthcare setting. The setting does not have any areas set aside for smoking.

What the quality statement means for patients and visitors

Patients and visitors of healthcare settings are not allowed to smoke anywhere in the grounds of the healthcare setting.

Source guidance

Definitions of terms used in this quality statement:

Healthcare settings
All publicly funded community, primary, secondary and tertiary healthcare facilities, including buildings, grounds and vehicles.

Equality and diversity considerations

People who are unable to leave the healthcare setting because of disability, vulnerability or detention under the Mental Health Act will have to abstain from smoking, unlike other people who can leave the grounds to smoke if they wish. Additional support should be provided for people unable to leave the healthcare setting, as defined in NICE guideline PH48.

Healthcare settings: nicotine-containing products and stop smoking pharmacotherapies

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Secondary healthcare settings ensure that a range of licensed nicotine containing products and stop smoking pharmacotherapies is available on site for patients, visitors and employees.

Rationale

Secondary healthcare services have a duty of care to protect the health of people who use or work in their services and promote healthy behaviour among these groups. Most secondary and tertiary healthcare settings already have a smokefree policy in place, which includes smokefree grounds. Facilitating abstinence (long term or temporary) among patients, visitors and employees (including contractors and volunteers) will help ensure compliance with smokefree policies.

Quality measures

Structure
a) Evidence of local arrangements to ensure that ‘stop smoking’ pharmacotherapies and licensed nicotine containing products are stocked by pharmacies within secondary healthcare services.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that a range of licensed nicotine containing products is available for sale within secondary healthcare services for visitors and employees.
Data source: Local data collection
Process
a) Proportion of secondary healthcare settings that stock pharmacotherapies and licensed nicotine containing products.
Numerator – The number in the denominator that stock pharmacotherapies and licensed nicotine containing products.
Denominator – The number of secondary healthcare settings in the specified geographic area.
Data source: Local data collection.
b) Proportion of secondary healthcare settings that sell nicotine containing products to visitors and employees.
Numerator – The number in the denominator that sell nicotine containing products to visitors and employees.
Denominator – The number of secondary healthcare settings in the specified geographic area.

What the quality statement means for directors and senior managers of secondary care services or their representatives, commissioners and people who work in secondary healthcare services

Directors and senior managers of secondary care services or their representatives ensure that compliance with a smokefree policy is facilitated by a range of licensed nicotine containing products and ‘stop smoking’ pharmacotherapies being available on site for patients, visitors and employees.
Commissioners ensure that their contracts with secondary healthcare settings facilitate compliance with a smokefree policy by including on site provision of licensed nicotine containing products and ‘stop smoking’ pharmacotherapies for patients, visitors and employees.
People who work in secondary healthcare services (including contractors and volunteers) are helped to stick to the smokefree policy by being able to obtain a range of licensed nicotine containing products and ‘stop smoking’ therapies on site.

What the quality statement means for patients and visitors

Patients in secondary healthcare services can obtain a range of licensed nicotine containing products and ‘stop smoking’ pharmacotherapies onsite at all times. This helps them follow the smokefree policy within the healthcare grounds.
Visitors can obtain a range of licensed nicotine containing products onsite at all times. This helps them follow the smokefree policy within the healthcare grounds.

Source guidance

Definitions of terms used in this quality statement

Secondary healthcare settings
All publicly funded secondary health and tertiary care facilities, including buildings, grounds and vehicles. This includes drug and alcohol services in secondary care, emergency care, inpatient, residential and long term hospital care for severe mental illness, psychiatric and specialist units and secure hospitals, and planned specialist medical care or surgery. It also includes maternity care provided in hospitals, maternity units, outpatient clinics and in the community. Care can be planned or emergency care. Planned secondary care generally follows a referral from a primary care provider, such as a GP. [NICE guideline PH48]
Licensed nicotine-containing products
Licensed nicotine containing products are a safe and effective way of reducing the amount people smoke. They can be used as a complete or partial substitute for tobacco, either in the short or long term.
Some nicotine containing products are not regulated by the Medicines and Healthcare products Regulatory Agency (MHRA) and, therefore, their effectiveness, safety and quality cannot be assured. These products are likely to be less harmful than cigarettes. For further details, see the MHRA website.
Different forms of nicotine containing products include:
  • patches
  • gum
  • inhalator
  • lozenges
  • nasal spray.
If alternative nicotine containing products (such as e cigarettes) gain licensing authorisation in the future, this quality statement will be reviewed.
‘Stop smoking’ pharmacotherapies
Pharmacotherapy is the treatment of addiction through the administration of drugs. ‘Stop smoking’ advisers and healthcare professionals may recommend and prescribe licensed nicotine containing products, varenicline or bupropion, as an aid to help people to stop smoking. Licensed nicotine containing products may also be offered to support temporary abstinence from smoking in the secondary healthcare setting.

Equality and diversity considerations

People whose drug treatment is affected by smoking may need to have the dosage of their drugs adjusted. This is particularly important for people with mental health problems taking antipsychotic medication.

Media campaigns

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Local authorities use regional and local media channels to reinforce national tobacco reduction campaigns.

Rationale

There is evidence that social marketing and media campaigns can stop people from taking up smoking and can be effective in changing smoking behaviour in those who already smoke. National campaigns that aim to reduce smoking in the community are run on a regular basis by the Department of Health and Public Health England. These should be communicated to local authorities in advance so that the campaign messages can be promoted and reinforced regionally and locally by all partners working together on tobacco control.

Quality measures

Structure
a) Evidence of local authorities using regional or local media channels to reinforce messages from national tobacco reduction campaigns.
Data source: Local data collection.
b) Evidence of regional and local activities to reinforce national tobacco reduction campaigns.
Data source: Local data collection.

What the quality statement means for local authorities and Public Health England

Local authorities supported by Public Health England use regional and local media channels to reinforce messages from national tobacco reduction campaigns. They may work in partnership to commission regional providers to improve cost effectiveness and consistency of the messages.

What the quality statement means for adults, children and young people

Adults, children and young people come into contact with campaign messages that put them off taking up smoking and encourage them to quit if they already smoke.

Source guidance

Definitions of terms used in this quality statement

Reinforcing national tobacco reduction campaigns locally
Reinforcing national tobacco reduction campaigns locally is likely to include some or all of the following:
  • Production and dissemination of local press releases.
  • Completion of radio and television interviews.
  • Delivery of local promotional events in community settings, for example, sports stadia, supermarkets, shopping centres and markets.
  • Production and dissemination of e information and e mail footers.
  • Dissemination of information through social media streams.
[NICE guideline PH14 and expert opinion]

Equality and diversity considerations

Smoking is more common in socially deprived areas and among people in routine and manual jobs. When developing campaigns, consideration should be given about how to target these groups, with what messages and via which media. Local campaigns should use local intelligence to tailor the activities so that they are effective for the local population.

Illicit tobacco: placeholder statement

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Preventing access to, demand for and supply of, illicit tobacco.

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence based guidance to be developed in this area.

What is illicit tobacco?

  • Cigarettes
    • ‘Illicit white’ cigarettes have no legal market in the UK. UK duty has not been paid and the appropriate health warnings and images may not be present. Some of these products may be legally sold in countries outside the UK.
    • Counterfeit cigarettes are illegally manufactured and sold by a party other than the original trademark or copyright holder. This can also include the counterfeiting of ‘illicit white’ cigarettes.
  • Genuine cigarettes intended for sale in another country may have been smuggled into the UK or duty free cigarettes may be sold illegally rather than kept for personal use.
  • Hand rolling tobacco
    • Non UK hand rolling tobacco brands are not intended for sale in the UK.
    • Counterfeit hand rolling tobacco is, like cigarettes, illegally manufactured and sold by a party other than the original trademark or copyright owner. It can also include the counterfeiting of non UK products. Genuine or UK hand rolling tobacco brands include products intended for both the UK and non UK markets. [Tackling illicit tobacco for better health]

Rationale

Illicit tobacco products make tobacco more accessible to children and young people, and those from socioeconomic groups already experiencing significant health inequalities. Illicit tobacco products are often half or a third of the price of duty paid products and can be accessed from a wide range of unregulated suppliers. Preventing children and young people and adults from accessing illicit tobacco is likely to have a significant effect on the rates of smoking and smoking uptake.

Services – access to antenatal care

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women are supported to access antenatal care, ideally by 10 weeks 0 days.

Quality measure

Structure
a) Evidence of local services that ensure antenatal care is readily and easily accessible.
b) Evidence of local arrangements to encourage pregnant women to access and maintain contact with antenatal care services.
Data source: a) and b) Local data collection. The NICE guideline CG110 baseline assessment tool can be used to assess current activity related to recording information for women presenting to antenatal care with complex social needs to inform mapping of the local population and to guide service provision.
Process
Proportion of pregnant women missing a scheduled antenatal appointment who are followed up within locally defined timescales.
Numerator – the number of women in the denominator followed up within locally defined timescales.
Denominator – the number of pregnant women missing a scheduled antenatal appointment.
Data source: Local data collection.
Outcome
a) Pregnant women accessing antenatal care who are seen for booking by 10 weeks 0 days.
b) Pregnant women accessing antenatal care who are seen for booking by 12 weeks 6 days.
c) Pregnant women accessing antenatal care who are seen for booking by 20 weeks 0 days.
d) Median gestation at booking.
e) Pregnant women accessing antenatal care attend at least the recommended number of antenatal appointments.
Data source: a), b) c) and d) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on booking appointment dates and estimated dates of delivery. The Care Quality Commission Maternity Services Survey 2010 asks the question ‘Roughly how many weeks pregnant were you when you had your ‘booking’ appointment (the appointment where you were given your pregnancy notes?)’. Possible responses are: before 8 weeks, 8 or 9 weeks, 10 or 11 weeks, 12 weeks and 13 or more weeks. The total number of respondents is also stated.
b) The Integrated Performance Measure Access to Midwifery is the collection of data to monitor women seen by a midwife or maternity health professional. This includes a national performance measure on the ‘percentage of women who have seen a midwife or a maternity healthcare professional for health and social care assessment of needs, risks and choices by 12 weeks and 6 days’. This is monitored by the Department of Health on a quarterly basis.
e) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on the date of attendance at an antenatal appointment (excluding first contact and booking). The Care Quality Commission Maternity Services Survey 2010 asks the question ‘Roughly how many antenatal check-ups did you have in total?’ Possible responses are: none, 1–6, 7–9, 10–14, 15 or more. The total number of respondents is also stated.

What the quality statement means for each audience

Service providers ensure that systems are in place to support pregnant women to access antenatal care, ideally by 10 weeks 0 days.
Healthcare and social care professionals support pregnant women to access antenatal care, ideally by 10 weeks 0 days. This includes following up women who have missed a scheduled antenatal appointment.
Commissioners ensure they commission services that are readily and easily accessible and that support pregnant women to access antenatal care, ideally by 10 weeks 0 days.
Pregnant women are encouraged to see a healthcare professional about their pregnancy as early as possible and have regular check-ups from their midwife or doctor throughout their pregnancy (antenatal care). This may include being contacted by their midwife or doctor if they miss a check-up.

Source guidance

Definitions

NICE full clinical guideline 62 acknowledges that the ‘booking appointment’ needs to be earlier in pregnancy (ideally by 10 weeks) than may have traditionally occurred.
NICE guideline CG62 recommends that the schedule of antenatal appointments is determined by the woman’s needs. For a woman who is nulliparous with an uncomplicated pregnancy, a schedule of 10 appointments should be adequate. For a woman who is parous with an uncomplicated pregnancy, a schedule of 7 appointments should be adequate.
Follow-up after a missed appointment may be undertaken by the maternity service or other community-based service the woman is in contact with, such as a children's centre, addiction service or GP. Follow-up should be via a method of contact that is appropriate to the woman, which may include:
  • text message
  • letter
  • telephone
  • community or home visit.

Equality and diversity considerations

Pregnant women include women with complex social needs who may be less likely to access or maintain contact with antenatal care services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol and/or drugs)
  • have recently arrived as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that localities give special consideration to these groups of women within the measures. NICE guideline CG110 has recommendations about how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.

Services – continuity of care

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women are cared for by a named midwife throughout their pregnancy.

Quality measure

Structure
a) Evidence of local arrangements and audit to ensure that pregnant women are cared for by a named midwife throughout their pregnancy.
b) Evidence of local arrangements to ensure that systems are in place to coordinate a pregnant woman's care should her named midwife not be available.
Data source: a) and b) Local data collection.
Process
The proportion of pregnant women with a named midwife.
Numerator – the number of women in the denominator with a named midwife.
Denominator – the number of pregnant women accessing antenatal care.
Data source: Local data collection.
Outcome
Pregnant women's satisfaction with the continuity of their antenatal care.
Data source: Local data collection. The Care Quality Commission Maternity Services Survey 2010 asks the question 'If you saw a midwife for your antenatal check-ups, did you see the same one every time?' Possible responses are: yes, every time; yes, most of the time; or no.

What the quality statement means for each audience

Service providers ensure that systems are in place to enable pregnant women to be cared for by a named midwife throughout their pregnancy.
Healthcare and social care professionals follow local systems and guidance to provide continuity of care to pregnant women through the provision of a named midwife.
Commissioners ensure they commission services that enable pregnant women to be cared for by a named midwife throughout their pregnancy.
Pregnant women are cared for a by a named midwife throughout their pregnancy.

Source guidance

Definitions

A named midwife is a named registered midwife who is responsible for providing all or most of a woman's antenatal and postnatal care and coordinating care should they not be available (definition adapted from Maternity matters: choice, access and continuity of care in a safe service).

Services – record keeping

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women have a complete record of the minimum set of antenatal test results in their hand-held maternity notes.

Quality measure

Structure
a) Evidence of local arrangements to ensure that pregnant women have a complete record of the minimum set of antenatal test results in their hand-held maternity notes.
b) Evidence of local audit to monitor the completeness and accuracy of antenatal test results in women's hand-held maternity notes.
Data source: a) and b) Local data collection.
Process
Proportion of pregnant women accessing antenatal care who have a complete record of the minimum set of antenatal test results in their hand-held maternity notes, appropriate to their stage of pregnancy.
Numerator – the number of women in the denominator with a complete record of the minimum set of antenatal test results in their hand-held maternity notes, appropriate to their stage of pregnancy.
Denominator – the number of pregnant women accessing antenatal care.
Data source: Local data collection. The NICE guideline CG110 baseline assessment tool and the NICE public health guidance 27 audit support, criterion 3.

What the quality statement means for each audience

Service providers ensure that systems are in place to maintain a complete record of the minimum set of antenatal test results in women's hand-held maternity notes.
Healthcare professionals ensure that women have a complete record of the minimum set of antenatal test results in their hand-held maternity notes.
Commissioners ensure they commission services that maintain a complete record of the minimum set of antenatal test results in women's hand-held maternity notes.
Pregnant women are given a complete record of the minimum set of their antenatal test results in their hand-held maternity notes.

Source guidance

Definitions

The minimum set of tests for routine scheduled antenatal care has been developed from the appointment schedule in appendix D of NICE guideline CG62.
Investigation
Timing
Blood pressure
All routine appointments
Urine test for proteinuria
All routine appointments
Blood group and rhesus D status
At booking
Haemoglobinopathies screen
At booking
Hepatitis B virus screen
At booking
HIV screen
At booking
Rubella susceptibility
At booking
Syphilis screen
At booking
MSU for asymptomatic bacteriuria
At booking
Height, weight and body mass index
At booking
Haemoglobin
At booking and 28 weeks
Red-cell alloantibodies
At booking and 28 weeks
Ultrasound scan to determine gestational age
Between 10 weeks 0 days and 13 weeks 6 days
Down's syndrome screen
Combined test: between 10 weeks 0 days and 14 weeks 1 day
Serum quadruple test:
14 weeks 2 days to 20 weeks 0 days
Ultrasound screen for structural anomalies
Between 18 weeks 0 days and 20 weeks 6 days
Measure of symphysis–fundal height
Fetal presentation
All routine appointments from 25 weeks
36 weeks
Women should be able to make an informed choice about whether to accept or decline each test, and notes should include a record of any tests offered and declined as well as the results of tests accepted

Equality and diversity considerations

Hand-held maternity notes and the information within them should be accessible to all women, including women who do not speak or read English and those with additional needs such as physical, sensory or learning disabilities.
Women should be able to choose whether to have all the results of their antenatal tests documented in their hand-held maternity notes. This may be particularly important when information is sensitive (for example, positive screening results for HIV, hepatitis B virus and syphilis). Where a woman declines to have antenatal test results documented in her hand-held notes, the results should instead be recorded within other medical notes.

Risk assessment – body mass index

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered personalised advice from an appropriately trained person on healthy eating and physical activity.

Quality measure

Structure
a) Evidence of local arrangements to ensure that pregnant women have their body mass index calculated and recorded at the booking appointment.
b) Evidence of local arrangements to ensure that pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered personalised advice from an appropriately trained person on healthy eating and physical activity.
Data source: a) and b) Local data collection. The NICE guideline PH27 self assessment tool.
Process
a) Proportion of pregnant women accessing antenatal care whose body mass index is calculated and recorded at the booking appointment.
Numerator – the number of women in the denominator whose body mass index is recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
b) Proportion of pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment who are offered personalised advice from an appropriately trained person on healthy eating and physical activity.
Numerator – the number of women in the denominator offered personalised advice from an appropriately trained person on healthy eating and physical activity.
Denominator – the number of pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment.
Data source: a) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on the following risk factors at booking: maternal height (global number 17209970) and weight (global number 17209960). The booking appointment date will also be available (global number 17201190). The NICE guideline PH27 audit support, criteria 1 and 3.
b) Local data collection.
Outcome
Women with a body mass index of 30 kg/m2 or more feel confident to make decisions about healthy eating and physical activity during their pregnancy.

What the quality statement means for each audience

Service providers ensure that systems are in place to offer pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice from an appropriately trained person on healthy eating and physical activity.
Healthcare professionals offer women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice on healthy eating and physical activity or if they are not appropriately trained to do this, refer them to an appropriately trained person.
Commissioners ensure they commission services that offer pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice from an appropriately trained person on healthy eating and physical activity.
Pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered advice relevant to them from an appropriately trained person on healthy eating and physical activity.

Source guidance

Definitions

An appropriately trained person can demonstrate expertise and competencies in weight management in pregnancy, including providing advice about nutrition and/or physical activity. This may include obstetricians, GPs, midwives, health visitors, nurses, dietitians, midwifery assistants, support workers and those working in weight management programmes (commercial or voluntary).

Equality and diversity considerations

The body mass index threshold may need adapting for different groups of pregnant women (for example, women from certain ethnic groups). NICE is developing public health guidance on body mass index and waist circumference in black and minority ethnic groups. A body mass index measure is considered unsuitable for use with those under 18.

Risk assessment – smoking cessation

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women who smoke are referred to an evidence-based stop smoking service at the booking appointment.

Quality measure

Structure
a) Evidence of local arrangements that pregnant women have their smoking status recorded at the booking appointment.
b) Evidence of local arrangements to ensure that pregnant women who smoke are referred to an evidence-based stop smoking service.
c) Evidence of local arrangements to ensure that pregnant women who smoke and decide not to attend an evidence-based stop smoking service receive follow-up.
Data source: a) Local data collection through Maternity Services Secondary Uses Dataset b) local data collection through PHQ30 and c) local data collection.
Process
a) Proportion of pregnant women accessing antenatal care whose smoking status is recorded at the booking appointment.
Numerator – the number of women in the denominator whose smoking status is recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
b) Proportion of pregnant women who smoke who are offered a referral to an evidence-based stop smoking service.
Numerator – the number of women in the denominator who are offered a referral to an evidence-based stop smoking service.
Denominator – the number of pregnant women accessing antenatal care who smoke.
c) Proportion of pregnant women who smoke who are referred to an evidence-based stop smoking service.
Numerator – the number of women in the denominator who are referred to an evidence-based stop smoking service.
Denominator – the number of pregnant women accessing antenatal care who smoke.
d) Proportion of pregnant women who smoke and decide not to attend an evidence-based stop smoking service who receive follow-up.
Numerator – the number of women in the denominator who decide not to attend an evidence-based stop smoking service who receive follow-up.
Denominator – the number of pregnant women who smoke and decide not to attend an evidence-based stop smoking service.
Data source: a) Local data collection. The Maternity Services Secondary Uses Dataset, once implemented, will collect data on 'the mother's self-reported smoking status at the Booking Appointment' (global number 17201020). b) Local data collection. c) Local data collection. d) Local data collection.
Outcome
a) Quit rates for pregnant women.
b) Smoking rates in pregnancy.
Data source: a) Local data collection.
b) The Smoking at Time of Delivery (SATOD) collection covers information on the number of women smoking and not smoking at time of delivery (childbirth). Each PCT (and a number of care trusts) is required to submit 3 figures each quarter:
  • total number of maternities
  • number of women known to smoke at the time of delivery
  • number of women known not to smoke at the time of delivery.
From 2011/12 quarter 3 onwards, the Information Centre for Health and Social Care has taken over responsibility for publishing 'Statistics on women's smoking status at time of delivery: England' from the Department of Health. The reports from 2011/12 quarter 3 are available from the Information Centre for Health and Social Care.
The Maternity Services Secondary Uses Dataset, once implemented, will collect data on 'the mother's self-reported smoking status, specifically after the birth of the baby' (global number 17207150).
PHQ30: Smoking quitters – Number of users of NHS stop smoking services who report that they are not smoking 4 weeks after setting a quit date. Data are broken down into sub-categories, which include 'Pregnant women setting a quit date and outcome'. Monitoring frequency: quarterly.

What the quality statement means for each audience

Service providers ensure that systems are in place to ensure that all pregnant women who smoke are referred to an evidence-based stop smoking service at their booking appointment.
Healthcare professionals refer all pregnant women who smoke to an evidence-based stop smoking service at their booking appointment.
Commissioners ensure they commission services which refer all pregnant women who smoke to an evidence-based stop smoking service at their booking appointment.
Pregnant women who smoke are referred to an evidence-based stop smoking service at their booking appointment.

Source guidance

Definitions

Advice on smoking cessation should be first provided at the booking appointment and when appropriate throughout the period of antenatal care. The midwife may provide the pregnant woman with information (in a variety of formats, for example a leaflet) about the risks to the unborn child of smoking when pregnant and the hazards of exposure to secondhand smoke for both mother and baby.
Women who smoke or have recently quit smoking should be referred to an evidence-based stop smoking service if:
  • they say they smoke, or
  • they have a carbon monoxide (CO) reading of 7 ppm or above, or
  • they say they have quit smoking in the past 2 weeks, or
  • they say they are a light or infrequent smoker but register a low CO reading (for example, 3 ppm).
[adapted from Quitting smoking in pregnancy and following childbirth (NICE guideline PH26)]
Evidence-based stop smoking services are 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 (NICE pathways: Evidence-based stop smoking services and quitlines).
At the time of referral the pregnant woman should be given the number of an evidence-based stop smoking service. This may include the number of the NHS Pregnancy Smoking Helpline (0800 1699 169), details of their website (http://smokefree.nhs.uk/smoking-and-pregnancy) and a number for a local helpline if one is available.

Risk assessment – gestational diabetes

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women are offered testing for gestational diabetes if they are identified as at risk of gestational diabetes at the booking appointment.

Quality measure

Structure
a) Evidence of local arrangements to ensure that pregnant women have their risk factors for gestational diabetes identified and recorded at the booking appointment.
b) Evidence of local arrangements to ensure that pregnant women identified as at risk of gestational diabetes at the booking appointment are offered testing for gestational diabetes.
Data source: a) and b) Local data collection.
Process
a) Proportion of pregnant women identified as at risk of gestational diabetes at the booking appointment who are offered testing for gestational diabetes.
Numerator – the number of women in the denominator offered testing for gestational diabetes.
Denominator – the number of pregnant women identified as at risk of gestational diabetes at the booking appointment.
b) Proportion of pregnant women identified as at risk of gestational diabetes at the booking appointment who receive testing for gestational diabetes.
Numerator – the number of women in the denominator receiving testing for gestational diabetes.
Denominator – the number of pregnant women identified as at risk of gestational diabetes at the booking appointment.
Data source: a) and b) Local data collection. The NICE guideline CG62 audit support, criterion 8 and 9. The Maternity Services Secondary Uses Dataset, once implemented, will collect data on the following risk factors at booking: maternal height (global number 17209970) and weight (global number 17209960), maternal family history of diabetes (global number 17200950) and ethnic group (global number 17200030), and obstetric diagnoses from previous pregnancies including gestational diabetes mellitus (global number 17200720). The date of the booking appointment will also be available (global number 17201190).
Outcome
Early identification of women with gestational diabetes.

What the quality statement means for each audience

Service providers ensure that systems are in place to offer pregnant women identified as at risk of gestational diabetes at the booking appointment testing for gestational diabetes.
Healthcare professionals offer pregnant women identified as at risk of gestational diabetes at the booking appointment testing for gestational diabetes.
Commissioners ensure they commission services that offer pregnant women identified as at risk of gestational diabetes at the booking appointment testing for gestational diabetes.
Pregnant women with a higher than normal chance of developing gestational diabetes (a type of diabetes that occurs during pregnancy) at the booking appointment are offered a test for gestational diabetes.

Source guidance

  • Antenatal care (2008) NICE guideline CG62, recommendations 1.2.2.2 and 1.9.1.1 (key priority for implementation).
  • Diabetes in pregnancy (2015) NICE guideline NG3, recommendations 1.2.5–1.2.7.

Definitions

Risk factors are taken from NICE guideline CG62:
  • body mass index above 30 kg/m2
  • previous macrosomic baby weighing 4.5 kg or above
  • previous gestational diabetes
  • family history of diabetes (first-degree relative with diabetes)
  • family origin with a high prevalence of diabetes:
    • South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh)
    • black Caribbean
    • Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt).
Women with any 1 of these risk factors should be offered testing for gestational diabetes.
Testing for gestational diabetes should be carried out in accordance with diabetes in pregnancy NICE guideline NG3:
Use the 2-hour 75 g oral glucose tolerance test (OGTT) ) to test for gestational diabetes in women with risk factors.
Offer women who have had gestational diabetes in a previous pregnancy:
  • early self-monitoring of blood glucose or
  • a 75 g 2-hour OGTT as soon as possible after booking (whether in the first or second trimester), and a further 75 g 2-hour OGTT at 24–28 weeks if the results of the first OGTT are normal.
Offer women with any of the other risk factors for gestational diabetes a 75 g 2-hour OGTT at 24–28 weeks.

Equality and diversity considerations

Any risk assessment for gestational diabetes should be corrected for family origin. Some family origins are risk factors for diabetes (see Definitions above) and people from these groups should be offered testing in accordance with the guidance.

Risk assessment – pre-eclampsia

July 2013: Quality statement 7 has been removed and is replaced by quality statement 2: Antenatal assessment of pre-eclampsia risk in Hypertension in pregnancy (NICE quality standard 35).

Risk assessment – intermediate risk of venous thromboembolism

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women at intermediate risk of venous thromboembolism at the booking appointment have specialist advice provided about their care.

Quality measure

Structure
a) Evidence of local arrangements to ensure that pregnant women have their risk of venous thromboembolism (VTE) assessed and recorded at the booking appointment.
b) Evidence of local arrangements to ensure that pregnant women at intermediate risk of VTE at the booking appointment have specialist advice provided about their care.
Data source: a) and b) Local data collection.
Process
a) Proportion of pregnant women accessing antenatal care who have their risk of VTE recorded at the booking appointment.
Numerator – the number of women in the denominator having their risk of VTE assessed and recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
b) Proportion of pregnant women at intermediate risk of VTE at the booking appointment who have specialist advice provided about their care.
Numerator – the number of women in the denominator with specialist advice provided about their care.
Denominator – the number of pregnant women at intermediate risk of VTE at the booking appointment.
Data source: a) and b) Local data collection.
Outcome
Incidence of VTE in pregnant women.
Data source: The Maternity Services Secondary Uses Dataset, once implemented, will collect data on VTE as a maternal critical incident (global number 17205700).

What the quality statement means for each audience

Service providers ensure that systems are in place to provide pregnant women who are at intermediate risk of VTE at the booking appointment with specialist advice.
Healthcare professionals seek or provide specialist advice for pregnant women at intermediate risk of VTE at the booking appointment.
Commissioners ensure they commission services which provide pregnant women at intermediate risk of VTE at the booking appointment with specialist advice.
Pregnant women who at the time of their booking appointment have a moderate risk of developing VTE (a blood clot) have specialist advice sought about their care.

Source guidance

Definitions

Definitions are taken from RCOG Green-top guideline 37a.
Intermediate risk of VTE is defined as any of the following:
  • single previous VTE with no family history or thrombophilia (inherited or acquired)
  • thrombophilia (inherited or acquired) and no VTE
  • medical comorbidities such as:
    • heart or lung disease
    • systemic lupus erythematosus
    • cancer
    • inflammatory conditions
    • nephrotic syndrome
    • sickle cell disease
    • intravenous drug use
  • surgical procedures such as appendicectomy
or 3 or more risk factors from the following list (or 2 or more risk factors from the following list if admitted to hospital):
  • age above 35 years
  • body mass index more than 30 kg/m2
  • parity 3 or more
  • smoker
  • gross varicose veins (symptomatic, above the knee or associated with phlebitis/oedema/skin changes)
  • current systemic infection
  • immobility (for at least 3 days) such as:
    • paraplegia
    • symphysis pubis dysfunction with reduced mobility
  • long-distance travel (greater than 4 hours)
  • pre-eclampsia
  • dehydration/hyperemesis/ovarian hyperstimulation syndrome
  • multiple pregnancy or assisted reproductive therapy.
Women assessed as being at intermediate risk should have specialist advice provided about their care. This would involve the healthcare professional responsible for the pregnant woman's care discussing the woman's risk factors with a specialist service (for example, a trust-nominated thrombosis in pregnancy expert or team) and acting on this advice.

Risk assessment – high risk of venous thromboembolism

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women at high risk of venous thromboembolism at the booking appointment are referred to a specialist service.

Quality measure

Structure
a) Evidence of local arrangements to ensure that pregnant women have their risk of venous thromboembolism (VTE) assessed and recorded at the booking appointment.
b) Evidence of local arrangements to ensure that pregnant women at high risk of VTE at the booking appointment are referred to a specialist service.
Data source: a) and b) Local data collection.
Process
a) Proportion of pregnant women accessing antenatal care who have their risk of VTE recorded at the booking appointment.
Numerator – the number of women in the denominator having their risk of VTE assessed and recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
b) Proportion of pregnant women at high risk of VTE at the booking appointment who are referred to a specialist service.
Numerator – the number of women in the denominator referred to a specialist service.
Denominator – the number of pregnant women at high risk of VTE at the booking appointment.
Data source: a) and b) Local data collection.
Outcome
Incidence of VTE in pregnant women.
Data source: The Maternity Services Secondary Uses Dataset, once implemented, will collect data on VTE as a maternal critical incident (global number 17205700).

What the quality statement means for each audience

Service providers ensure that systems are in place to provide pregnant women at high risk of VTE at the booking appointment with onward referral to a specialist service.
Healthcare professionals refer pregnant women at high risk of VTE at the booking appointment to a specialist service.
Commissioners ensure they commission services which provide pregnant women at high risk of VTE at the booking appointment with onward referral to a specialist service.
Pregnant women who at the time of their booking appointment have a high chance of developing VTE (a blood clot) are referred to a specialist service.

Source guidance

Definitions

Definitions are taken from RCOG Green-top guideline 37a.
High risk of VTE is defined as any of the following:
  • single previous VTE and thrombophilia (inherited or acquired) or family history
  • single previous unprovoked/oestrogen-related VTE
  • previous recurrent VTE (more than 1).
Women assessed as being at high risk should be referred to a specialist service, for example a trust-nominated thrombosis in pregnancy expert or team.

Screening – national fetal anomaly screening programmes

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women are offered fetal screening in accordance with current UK National Screening Committee programmes.

Quality measure

Structure
Evidence of local NHS-commissioned services to ensure that all pregnant women are offered fetal screening in accordance with current UK National Screening Committee programmes.
Data source: a) and b) Local data collection.
Process
Note a pregnant woman would be offered either process a) or b) and always process c).
a) Proportion of pregnant women booking before 14 weeks 2 days who are offered the combined screening test to take place between 10 weeks 0 days and 14 weeks 1 day.
Numerator – the number of women in the denominator offered the combined screening test to take place between 10 weeks 0 days and 14 weeks 1 day.
Denominator – the number of pregnant women booking before 14 weeks 2 days.
b) Proportion of pregnant women booking between 14 weeks 2 days and 20 weeks 0 days who are offered the quadruple screening test for Down's syndrome to take place between 14 weeks 2 days and 20 weeks 0 days.
Numerator – the number of women in the denominator offered the quadruple screening test for Down's syndrome to take place between 14 weeks 2 days and 20 weeks 0 days.
Denominator – the number of pregnant women booking between 14 weeks 2 days and 20 weeks 0 days.
c) Proportion of pregnant women booking before 21 weeks who are offered ultrasound screening for fetal anomalies to take place between 18 weeks 0 days and 20 weeks 6 days.
Numerator – the number of women in the denominator offered ultrasound screening for fetal anomalies to take place between 18 weeks 0 days and 20 weeks 6 days.
Denominator – the number of pregnant women booking before 21 weeks.
Data source: a), b) and c) Local data collection.
a) The Care Quality Commission Maternity Services Survey 2010 asks the following questions: 'Did you have a dating scan? This takes place between 8–14 weeks of pregnancy' and 'Did you have any screening tests (a blood test or nuchal scan) to check whether your baby might have Down's syndrome?' Possible responses to the latter are: 'yes, a blood test only'; 'yes, a nuchal scan only'; 'yes, a nuchal scan and blood test'; and 'no, I wasn't offered any screening tests for Down's syndrome'. The total number of respondents is also stated.
a), b) and c) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on 'whether or not screening for Down's Syndrome was offered, accepted or declined' (global number 17202360), 'date blood test sample taken for Down's Syndrome screening' (global number 17202410), 'whether or not fetal anomaly screening was offered, accepted or declined' (global number 17203180) and 'date and time on which fetal anomaly screening was undertaken' (global number 17203190).
a), b) and c) QOF indicator MAT1 – Antenatal care and screening are offered according to current local guidelines (Additional services domain).
c) The Care Quality Commission Maternity Services Survey 2010 asks the question 'Did you have a scan at around 20 weeks of pregnancy?' The total number of respondents is also stated.
Outcome
a) Pregnant women feel they have made an informed decision about whether to undergo fetal anomaly screening.
b) Screening uptake rates.

What the quality statement means for each audience

Service providers ensure that systems are in place to offer fetal screening to pregnant women in accordance with current UK National Screening Committee programmes.
Healthcare professionals offer fetal screening to pregnant women in accordance with current UK National Screening Committee programmes.
Commissioners ensure they commission services that offer fetal screening to pregnant women as part of NHS care, in accordance with current UK National Screening Committee programmes.
Pregnant women who access antenatal care before 21 weeks are offered an ultrasound scan to screen for various conditions in their unborn baby.
In addition, pregnant women who access antenatal care before 20 weeks are offered screening for Down's syndrome in their unborn baby. The type of test carried out (for example, an ultrasound scan and a blood test or just a blood test) will depend on how far advanced the pregnancy is.

Source guidance

Definitions

Current UK National Screening Committee programmes for fetal screening are defined here as the National Screening Committee policy on fetal anomaly screening in pregnancy, which includes both fetal anomaly ultrasound, and Down's syndrome screening.
UK National Screening Committee recommendations (Screening for Down's syndrome: UK NSC Policy recommendations 2011–2014 Model of best practice) state that the gestational age window for the combined test runs from 10 weeks 0 days to 14 weeks 1 day. The combined test is made up of linear fetal measurement of the crown-rump length to estimate fetal gestational age (dating scan), measurement of the nuchal translucency space at the back of the fetal neck, and maternal blood to measure the serum markers of pregnancy associated plasma protein A and human chorionic gonadotrophin hormone. In striking a balance between the benefits of all the markers, trusts should consider screening women around 11 weeks 2 days.
For women presenting beyond 14 weeks 1 day, the quadruple test (maternal serum) window runs from 14 weeks 2 days to 20 weeks 0 days.
The fetal anomaly ultrasound scan should be offered at first contact visit or booking visit, to take place between 18 weeks 0 days and 20 weeks 6 days.

Equality and diversity considerations

The offer and implications of screening should be understood by all women to enable them to make informed decisions. This will necessitate provision of information in an accessible format (particularly for women with physical, sensory or learning disabilities and women who do not speak or read English).

Fetal wellbeing – external cephalic version

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) are offered external cephalic version.

Quality measure

Structure
a) Evidence of local arrangements to ensure that pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins) are referred for confirmatory ultrasound assessment.
b) Evidence of local arrangements to ensure that pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) are offered external cephalic version.
Data source:a) and b) Local data collection.
Process
a) Proportion of pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins) who are referred for confirmatory ultrasound assessment.
Numerator – the number of women in the denominator referred for confirmatory ultrasound assessment.
Denominator – the number of pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins).
b) Proportion of pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who are offered external cephalic version.
Numerator – the number of women in the denominator offered external cephalic version.
Denominator – the number of pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins).
Data source: a) and b) Local data collection.
Outcome
a) External cephalic version rates.
b) Mode of delivery including:
  • rates of vaginal birth, emergency and elective caesarean section after successful external cephalic version
  • rates of vaginal birth, emergency and elective caesarean section after unsuccessful external cephalic version
  • rates of vaginal birth and emergency caesarean section after diagnosis of breech presentation in labour.
Data source: a) and b) Local data collection.
b) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on 'the presentation of the (first) fetus at onset of labour (including option of breech)' (global number 17204960), 'instance of a critical incident occurring (including option of undiagnosed breech)' (global number 17205700), 'the method for delivering baby' (global number 17206160).

What the quality statement means for each audience

Service providers ensure that systems are in place to offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) external cephalic version.
Healthcare professionals offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) external cephalic version.
Commissioners ensure they commission services that offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) external cephalic version.
Pregnant women with a single baby in the breech position (bottom first with knees either flexed or extended) but with no other problems at 36 weeks or later in their pregnancy are offered external cephalic version (a procedure to move the baby round to the head first position), which includes first having an ultrasound scan to confirm the baby's position.

Source guidance

  • Antenatal care (2008) NICE clinical guideline 62, recommendations 1.10.5 and 1.11.2.1.

Definitions

As detailed in NICE clinical guideline 62 recommendation 1.11.2.1 women in labour or those with 1 or more of the following obstetric complications should not be offered external cephalic version:
  • a uterine scar or abnormality
  • fetal compromise
  • ruptured membranes
  • vaginal bleeding
  • medical conditions.
When obtaining informed consent for this procedure the woman should be provided with balanced information about the benefits and risks of external cephalic version (for example, the Royal College of Obstetricians and Gynaecologists patient information leaflet 'Turning a baby in the womb (external cephalic version) – information for you').

Equality and diversity considerations

There may be some women whose breech presentation is not identified and who are not offered an external cephalic version.

Fetal wellbeing – membrane sweeping for prolonged pregnancy

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Nulliparous pregnant women are offered a vaginal examination for membrane sweeping at their 40- and 41-week antenatal appointments, and parous pregnant women are offered this at their 41-week appointment.

Quality measure

Structure
Evidence of local arrangements to ensure that nulliparous pregnant women are offered a vaginal examination for membrane sweeping at their 40- and 41-week antenatal visits, and parous pregnant women are offered this at their 41-week appointment.
Data source: Local data collection.
Process
a) Proportion of nulliparous pregnant women attending a 40-week antenatal appointment who are offered a vaginal examination for membrane sweeping.
Numerator – the number of women in the denominator offered a vaginal examination for membrane sweeping.
Denominator – the number of nulliparous pregnant women attending a 40-week antenatal appointment.
b) Proportion of nulliparous pregnant women attending a 41-week antenatal appointment who are offered a vaginal examination for membrane sweeping.
Numerator – the number of women in the denominator offered a vaginal examination for membrane sweeping.
Denominator – the number of nulliparous pregnant women attending a 41-week antenatal appointment.
c) Proportion of parous pregnant women attending a 41-week antenatal appointment who are offered a vaginal examination for membrane sweeping.
Numerator – the number of women in the denominator offered a vaginal examination for membrane sweeping.
Denominator – the number of parous pregnant women attending a 41-week antenatal appointment.
Data source: a), b) and c) Local data collection.
Outcome
a) Rates of induction of labour for women with prolonged pregnancy.
b) Mode of delivery for women with prolonged pregnancy including:
  • spontaneous vaginal birth
  • instrumental vaginal birth
  • elective or emergency caesarean section.
c) Rates of stillbirth beyond 40 weeks gestation (where there is no underlying medical cause).
Data source: a), b) and c) Local data collection.
a), b) and c) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on 'the medical induction of labour' (global number 17204740), 'the method for delivering baby' (global number 17206160) and neonatal death (global number 17209680).

What the quality statement means for each audience

Service providers ensure that systems are in place to offer nulliparous pregnant women a vaginal examination for membrane sweeping at their 40- and 41-week antenatal appointments, and parous pregnant women the same at their 41-week appointment.
Healthcare professionals offer nulliparous pregnant women a vaginal examination for membrane sweeping at their 40- and 41-week antenatal visits, and parous pregnant women the same at their 41-week appointment.
Commissioners ensure they commission services that offer nulliparous pregnant women a vaginal examination for membrane sweeping at their 40- and 41-week antenatal appointments, and parous pregnant women the same at their 41-week appointment.
Pregnant women having their first baby are offered a vaginal examination at their 40- and 41-week antenatal appointments to carry out a membrane sweep, in which a healthcare professional moves a finger around the cervix or massages the cervix, to help start labour.
Pregnant women having their second or later baby are offered a vaginal examination at their 41-week appointment to carry out a membrane sweep, in which a healthcare professional moves a finger around the cervix or massages the cervix, to help start labour.

Source guidance

Effective interventions library

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).

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 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).

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.

Successful effective interventions library details

Implementation

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

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.

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).
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.

Paths in this pathway

Pathway created: May 2011 Last updated: August 2015

© NICE 2015

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