nice guidance for supporting smokers in secondary care

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NICE guidance for supporting smokers in secondary care. John Britton. Context Evidence reviews Main findings Responses. PDG members NICE staff. Matthew Alford Community Member Gary Bickerstaffe Health Improvement Specialist John Britton Professor of Epidemiology - PowerPoint PPT Presentation


Part 1: From the beginning, to 1962

NICE guidance for supporting smokers in secondary careJohn Britton

Thank organisers, welcome on behalf of srnt and ukctcs,

Stress this is predominantly european union

by way of introduction to ukctcs.....1


Evidence reviews

Main findings


PDG members NICE staffMatthew AlfordCommunity MemberGary Bickerstaffe Health Improvement SpecialistJohn Britton Professor of EpidemiologyJonathan Campion Consultant PsychiatristAmanda FarleyLecturer in EpidemiologyElizabeth FisherHealth Improvement ManagerLiz Gilbert NCSCTGill Grimshaw Community MemberYvonne Hermon Smoking and Pregnancy CoordinatorJo McCullagh Tobacco Control /SSSLisa McNally Consultant in Public HealthJohn Moxham Professor of Respiratory MedicineRachael MurrayLecturer Health PolicyCarmel O'Gorman Specialist MidwifeShalini PatniConsultant ObstetricianGiri RajaratnamDeputy Regional Director PHEElena RatschenLecturer, Tobacco ControlFraser SerleCommunity MemberMatthew Taylor York Health Economics ConsortiumHilary Wareing Tobacco Control Collab. Centre

Tricia YoungerAssociate Director (to 12.12)Simon EllisAssociate Director (from 12.12)Pete ShearnLead AnalystAmanda KilloranAnalyst (until June 2012)Linda SheppardAnalystPatti WhiteAnalystLesley OwenHealth EconomicsPatricia MountainProject ManagerDenise JarrettCoordinatorSue JelleySenior Editor (to 2.13)Jaimella EspleySenior Editor (from 2.13)Alison LakeEditor (until May 2013)Rebecca BoucherEditor (from May 2013)

Mike Kelly CPH DirectorTonya Gillis Press and Media

Smoking and NHS secondary care, England 2011 million adult admissions/year1.5 million for diseases caused by smoking463,000 attributable to smoking25% of respiratory 81% of lung cancer 86% COPD15% cardiovascular11% cancer

Smoking in people admitted to English hospitals, 2010-11 Szatkowski et al, preliminary dataTotal of ~ 2.6 million smokers admitted to hospital

NICE guidance on tobacco dependence

Treatments, either separately or combined, including:brief interventions [by healthcare professionals]individual or group behavioural counsellingNRT, varenicline or bupropion pharmacotherapyself-help materialsDelivered by NHS Stop Smoking Services with adequate staffing and a full-time coordinator]

Targets for the number of smokers using the service [5% of population] and one-month quit rates [35% ]What is an effective stop smoking intervention?

Evidence sources: Commissioned reviewsEffects of nicotine Smoking cessation interventions in acute and maternity serviceseffectivenessbarriers and facilitatorsSmoking cessation interventions in mental health servicesEffectivenessBarriers and facilitators Smoke-free strategiesEffectivenessBarriers and facilitators Cost effectivenessStop smoking interventions in secondary care Streamlined secondary care system: project reportRCT of systematic identification and treatment of smokersAssociation between smoking and mental disorders Smoking in people with mental health problemsEthics of smoking cessation and smoke-free policiesSouth London and Maudsley NHS Trust Smoke-free pilotEvidence sources: Expert papersEvidence reviews: Nicotine effectsNo RCT signal of risk in terms of adverse events, changes in CVD, MI or strokeNo evidence of adverse effect on : stable CVDunstable CVDbone healing surgical complicationsWeak evidence that NRT should be removed before microvascular reconstructive surgeryIncreased insulin resistance, though < smokingPositive effect in ulcerative colitisSmoking cessation interventions in acute servicesIntensityContentEffectAdd drug*1Single contact + written/other material, no follow upNoneNo effect2Longer or more contacts + other materials but not beyond quit dateNoneNo effect3Any contact + follow-up after quit date but 4 weeks follow-up Works(OR 1.51)Works(OR 1.66)5Any contact + follow-up with face-to-face contact for > 4 weeks Works best(OR 1.28)Works best(OR 2.26)Validated! Validated! *(typically NRT)NRT has most effect. Others less convincing. Pregnancy not nec nrt15Smoking cessation interventions: maternity services(behavioural only; NRT ineffective)IntensityContentTo termPost-partum1Single contact + written/other material, no follow upNo effectNo effect2Longer or more contacts + other materials but not beyond quit dateNo effect*No effect*3Any contact + follow-up after quit date but 4 weeks follow-up Works(OR 1.72)No effect

5Any contact + follow-up with face-to-face contact for > 4 weeks Works (OR 1.34)No effect6Incentives

Works(OR 5.77)Works (OR 5.86)*(or findings based on poor quality studies)Validated! Validated! Validated! Validated! NRT has most effect. Others less convincing. Pregnancy not nec nrt16Barriers to intervention in acute and maternity servicesStaff smokingLack of time, knowledge, skills, trainingPoor organisational support referral processes, prompts, automated systems, auditNo or limited access to behavioural support and medicinesConcern that stopping smoking before surgery increases risks[no pre-planning for admission]

Smoking and mental healthAbstinence from smoking exacerbates mental health symptomsNicotine therapy relieves these negative symptomsSmoking cessation does not exacerbate psychosisimproves depressionreduces clozapine, olanzapine, some antidepressant dose requirementsdoes not affect other substance abuse treatmentBupropion not contra-indicated in severe mental illness(likewise varenicline, post review)Mixed evidence on effect of smoke-free policy on behaviour

Cessation interventions in mental health settings:Evidence very limitedHigh intensity behavioural interventions effective, but less soNRT evidence limited, but dual therapy better than singlebupropion effective in schizophrenia Short term OR 3.80 95% CI 1.58-9.15Medium term OR 3.00 95% CI 1.29-7.00 Long term OR 1.60 95% CI 0.23-11.01 Varenicline evidence limited at time of review

Barriers in mental health settingsAs for acute trusts, but also:smoking part of culturestaff-facilitated smoking breaks part of ward routinesmoking used as means of control/build relationshipsbelief that stopping smokingexacerbates mental health problemsincreases need for medicationBelief that smoke-free policies will Discourage use of inpatient and outpatient services cause abuse, aggression, firespaternalism (their only pleasure)

Short and long-term incremental costs per QALY(Intensity 4 and 5 with pharmacotherapy) NICE 2013 3 years (approx costs/range of costs)LifetimePreoperative patientsDominantDominantCOPD7000-9000DominantCardiacDominantDominantAcute general (22,000)DominantSchizophrenian/a2000-3000

Pregnancy (behaviour only)Dominant to 155000Dominant to 15000Staff (intervention)Staff (smoke-free policy)4000DominantDominantDominantAcute gen is pharmacology effect21Smoke-free sitesEffective in reducing smoking on hospital siteProbably effective in reducing staff smokingNo clear evidence of exacerbation of aggressive or disruptive behaviour in mental health settings Succeed, given leadership and planning to change cultureEffective cessation and temporary abstinence support to patients and staff essentialNCSCT Streamlined Secondary Care System

Effectiveness of NHS SSS referral from hospital3-month Pilot at Queen Alexandra Hospital, Portsmouth.

RCT of integrated smoking interventionMurray et al, BMJ 2013;347:f4004Behavioural & Developmental Psychiatry CAG500 staff, 10 wards, 162 beds 92% smoking on forensic wardsSmoke-free from 13.3.13Sustained preparation for patients and staffMarked reduction in smoking incidentsImproved ward routines and engagementSuccessful

South London and Maudsley Smoke-free pilot Mary Yates RNHM, RMN, MSc. Matron

Smoking and mental health: Ethical considerationsRichard Ashcroft, Queen Marys, University of London Smoking is as important and deserving of intervention in people with mental disorder as in anyone Smoking cessation and smoke-free policies are just as important in mental health settings as elsewhere in NHSThis patient group may need more, and more intensive, interventions and hence more investment A need to see health, and not just mental health (or order, discipline and safety), as a key institutional goal of mental health, and prison/youth offender institutions

Stopping smoking at any time has considerable health benefits Secondary care providers have a duty of care to protect the health of, and promote healthy behaviour among, people who use or work in their servicesStrong leadership and good management required to:make premises and grounds smoke-freeHelp staff to stop smoking, or else abstain while identifiable as NHS staffTrain staff to support people to stop smokingEnsure that cessation services provided onsiteHelp patients, visitors and other users plan for admission

Strategy, policy and commissioningInformation, advice and support

For patients:Identify smokers and advise cessation/temporary abstinence at first face-to-face contactProvide pharmacotherapy and intensive behavioural support, immediately if necessary, or else within 24 hoursProvide behavioural support as often and as long as needed during admission.Provide or arrange follow up after dischargeManage doses of clozapine, olanzapine, theophylline, warfarinEngage with family and friends

Commission smoke-free servicesAssign senior director to implement smoking policy and careMake buildings and grounds smoke-freeCommunicate policy to public, staff, contractors, all service usersNo designated smoking areas or staff-facilitated smoking breaksEnsure NRT available for sale to visitorsSupport staff to stop smoking in groundsTrain staff to