Problems quitting smoking? 'Inhale less' NICE advises

The BBC splashed the headline, “Struggling to quit? Inhale less, smokers told [sic]”. It reported how “smokers who struggle to quit should inhale less, or stop during set points of the day such as work” based on new draft guidelines issued by the National Institute for Health and Clinical Excellence (NICE).

The headlines highlight that the NHS has traditionally focused on advising smokers to quit completely, but suggest the new draft document indicates a different approach is being tried for those who are most addicted and may not be advised to go “cold turkey”.

However, the draft guidance clearly states that giving up smoking completely is still the best option all round, and remains NICE’s recommendation. Still, the guidelines acknowledge that there is a ‘hardcore’ of smokers who often find it difficult to go cold turkey, or are reluctant to. So it says that a more realistic and pragmatic approach for these people would be “harm reduction strategies”.

This approach can include using nicotine replacement therapies, such as gum or patches, smoking less, or temporarily stopping smoking, for example, during working hours.

The bottom line of the draft guidance is that giving up smoking completely is still regarded as the most effective way to quit smoking. However, health services should not ignore the benefits that harm-reduction options offer, not least in terms of being the first step to quitting for some, and the reduction in harm to the smokers and those around them.

Why was the guidance produced?

The new draft guidance highlights the fact that smoking is the single greatest cause of preventable illness and early death in England, accounting for 79,100 deaths among adults aged over 35 in 2011.

Second-hand smoke also causes an estimated 11,000 deaths a year in the UK, from conditions such as lung cancer, stroke, and heart disease.

This latest draft guidance was produced by NICE on behalf of the Department of Health and aims to reduce illnesses and deaths caused by smoking tobacco among smokers and those around them.

This draft guidance had been released for consultation and any comments will be considered before the final guidance document is issued in the future. The final guidelines are expected to be released in May 2013.

NICE has previously published a number of guidance documents on the topic of smoking, including advice on:

• NHS smoking cessation services
• specific treatments for stopping smoking
• quitting smoking in pregnancy and following childbirth
• working with schools to prevent children from starting smoking
• stopping smoking in workplaces
• stop smoking advice for South Asian communities

What are the key recommendations of the new guidance?

The NICE draft guidance states that people can reduce illnesses and deaths from smoking by using “harm reduction approaches”. As most harm from smoking comes from the other compounds in the tobacco mixture, rather than the nicotine, a key part of this strategy relies on substituting tobacco products for less harmful nicotine-containing products, such as patches or gum. This approach is known as nicotine replacement therapy (NRT).

In contrast to going “cold turkey” and giving up smoking all together (while still using NRT, as recommended by NICE), “harm reduction” approaches involve the continued use of tobacco or nicotine, while reducing the harm caused by tobacco to the smoker and others. The options to reduce harm from smoking put forward in the guidance included:

• *Stopping smoking
  *Quit smoking in one step with the help of one or more licensed types of NRT and continuing to use these products as a substitute for tobacco, possibly indefinitely – which would be regarded as the ideal ‘treatment of choice’.
• Cutting down before quitting
  Cut down prior to quitting, by smoking fewer cigarettes or inhaling or smoking less of each cigarette, with or without the help of one or more licensed nicotine-containing products.
• *Smoking less
  *Smoke less, by smoking fewer cigarettes, inhaling less or smoking less of each cigarette, with or without the help of one or more licensed nicotine containing products.
• *Abstaining from smoking temporarily
  *Temporarily abstain, with or without the help of one or more licensed nicotine containing products. This could be for a specific occasion (for example, while in hospital), for regular events (for example, when at work or in the home).

Nicotine replacement therapy (NRT)

A number of manufactured products contain nicotine without tobacco. Some are regulated by the Medicines and Healthcare products Regulatory Agency (MHRA) to ensure they are effective, deliver nicotine safely, and are manufactured to a consistent quality standard.

Alternative nicotine devices, such as electronic cigarettes, are not currently regulated by the MHRA, although a decision on this is imminent. While they contain no tobacco, a number of news stories earlier this year raised concerns that so called ‘e-cigarettes’ may still cause lung damage.

The guidance recommends the need for consistent information about their safety so that people can make informed choices. Therefore, the daft guidance recommends using only “licensed nicotine containing products”, meaning those that are regulated by the MHRA.

What do they mean by 'inhaling less' and how do I go about it?

It is not clear from the draft guidance exactly what constitutes “inhaling less”, as splashed in the BBC headline. Given that smokers inhale different amounts of smoke to begin with, it would be useful to know if there is a threshold of smoke intake, below which health benefits can be gained, or whether simply smoking less, whatever the starting point, is beneficial. However, the guidance also advises temporary gaps in smoking, or smoking less of each cigarette (don’t smoke it to the filter).

Those who are interested may have to wait until the full guidance is released for further details on exactly what constitutes inhaling less.

Alternatively, smokers may wish to speak to a stop smoking advisor to find out more about this and other ways to quit or reduce their smoking.

Read more information about the range of NHS Stop Smoking services that are available.

Does this guidance differ from previous advice?

The draft guidance maintains that quitting smoking altogether is the best and most cost effective way to improve the health of someone who smokes. In this way, it does not differ from previous guidance.

However, it acknowledges that harm reduction methods deserve a place alongside existing methods, and that these will be especially useful for those who do not want to, or are unable to, quit in one step. Previous guidance has tended to focus on efforts to quit altogether, so the addition of harm reduction approaches to the mix serves to extend the arsenal of methods that stop smoking services can discuss with smokers who are considering quitting.

The bottom line from the draft guidance is that offering harm-reduction strategies (as well as advice to stop completely), may ultimately increase the number of people who quit smoking and can help reduce the harm to smokers and those around them.

Is the evidence reliable?

The draft guidance clearly highlights that “there is a lack of (and limited) evidence on the effectiveness of harm-reduction strategies to tackle smoking (including evidence on any unintended consequences)” and added that the “long term health benefits of smoking less are uncertain”.

The lack of evidence may not necessarily be because harm-reduction strategies are ineffective, but because, with the exceptions of a few clinical trials assessing individual effects, they have not been studied on large groups of people, at a so-called “population level”.

In terms of NRT, evidence was available from studies with up to five years follow-up, which suggests that ‘pure’ nicotine, in the form available in NRT products, does not pose a significant health risk. This is the case whether it is used as a substitute for, or in combination with, cigarettes. Although there is a lack of data on using NRT products beyond 5 years, expert opinion is that lifetime use will be considerably less harmful than smoking.

The evidence that stopping smoking improves health and reduces the incidence of death and disease, compared to those who continue to smoke, is overwhelming and conclusive.

What are the implications of this guidance on the future of NHS Stop Smoking Services?

The guidance acknowledges that most smokers adopt harm-reduction practices on their own, but concluded that some people may benefit from advice about the different strategies and support available through stop smoking services. 

The draft guidance team indicated that service-level guidance would be needed to outline the new range of support on offer to people trying to quit smoking, but who are unable (or unwilling) to give up nicotine completely.

The guidance team highlighted the following issues that would need consideration and resolution:

• the length of time clients would be able to use the service
• how long NRT products could be prescribed – and paid for – from public funds
• the type of target-setting or performance measures that would be appropriate for harm-reduction strategies
• the way people who want to smoke less are supported

The guidance also indicated that the name of current services, “NHS Stop Smoking Services” may need to be rebranded to reflect the new harm reduction strategies. It stopped short of suggesting alternative names.

If you want to contribute to the consultation on this draft guidance, you can email your comments to tobaccoharmreduction@nice.org.uk