Implementing the NICE Guidance on Tobacco Harm Reduction

1. Implementing the NICE Guidance on Tobacco Harm Reduction Linda Bauld Professorof Health Policy, University of Stirling Hazel Cheeseman Policy and Campaigns Manager, ASH

2. Workshop agenda • Brief overview of the NICE guidance (Linda - 10 minutes) • Examples from the rest of the country (City of London, Leicester, Devon – 20 minutes) • Overview of activity across England (Hazel – 5minutes) • Discussion of implementation issues emerging (Linda/ Hazel to facilitate – 40 minutes) Resources available for participants: revised guidance materials, NCSCT notes on ecigs and HR

3. Guidance focus 1 • The guidance aims to reduce illnesses and deaths from smoking tobacco among people who smoke and those around them. This can be done by: • stopping smoking • cutting down prior to stopping smoking • smoking less • abstaining from smoking temporarily. • Harm reduction approaches should be seen as complementary to existing Stop Smoking Services. • The aim is to extend the reach of services and draw people who previously would not have used the services.

4. Guidance focus 2 • The guidance focus is about helping people, particularly those who are highly dependent on nicotine, who: • may not be able (or do not want) to stop smoking in one step • may want to stop smoking, without necessarily giving up nicotine • may not be ready to stop smoking, but want to reduce the amount they smoke

5. Licensed Nicotine Products • Harm reduction approaches in the NICE guidance can involve substituting the nicotine in tobacco with less harmful, nicotine-containing products. • These include NRT products that are licensed by the MHRA as pharmaceutical treatments for smoking. • The guidance only recommends the use oflicensed products, recognising that electronic cigarettes may become licensed in the future. • Nicotine-containing products might be used either temporarily or indefinitely, and as a partial or complete substitute for tobacco

6. Nicotine-containing products The guidance states that: • There is reason to believe that lifetime use of licensed nicotine-containing products will be considerably less harmful than smoking • There is little direct evidence on the effectiveness, quality and safety of nicotine-containing products that are not regulated by the MHRA. However, they are expected to be less harmful than tobacco.

7. Harm reduction options in the guidance • Stop smoking in one step then use licensed nicotine products, possibly indefinitely. • Cut down prior to quitting with or without the help of licensed nicotine-containing products. • Smoke less with or without the help of one or more licensed nicotine-containing products. • Temporarily abstain with or without the help of one or more licensed nicotine-containing products.

8. Percentage of smokers reporting a previous quit attempt as a function of harm reduction activities Source: Beard, E., & West. R. (2012). Addiction

9. Raising awareness of licensed nicotine containing products Self-help materials Choosing a harm reduction approach Behavioural support Advising on licensed nicotine-containing products Supplying licensed nicotine-containing products Follow-up appointments Content of Recommendations 1-7

10. Supporting temporary abstinence People within closed institutions; such as secure mental health units, or prisons Staff working in closed institutions Commissioning stop smoking services Education and training for practitioners Point of sale promotion of licensed nicotine containing products Manufacturer information on licensed nicotine containing products Content of Recommendations 8-14

11. Health economics • An economic model assessed a range of potential harm-reduction approaches. All interventions in the model - apart from temporary abstinence with no support - were highly cost effective. • Only when a licensed nicotine containing product is provided for more than 5 or 10 years, and the quit rate is less than 6%, do the costs (to the NHS) potentially outweigh the benefits • Economic modelling showed: for an intervention that achieves 1 additional 'reducer' it will saveapproximately £767 over the person's lifetime • By offering services to help people to reduce the amount they smoke, more people may present for treatment.

12. Considerations • The guidance covers individual level approaches to harm reduction. These need to be supported by wider tobacco control policies • The guidance clarifies the current limitations of the evidence regarding NCPs other than NRT, and outlines the links with the MHRA’s work • The guidance was updated in July 2013 to reflect the MHRA decision that all nicotine-containing products should be regulated.

13. Evidence gaps • Gaps in the evidence were identified during guidance development, particularly on:- population level harm reduction strategies- the benefits of smoking less- longer term NRT use (beyond 5 years)- e-cigarettes • The guidance includes research recommendations, particularly on the need for surveillance studies of harm reduction strategies and the impact of these strategies on different sub-populations.

14. Examples from the rest of the country • Devon • City of London • Leicester

15. Harm Reduction Task & Finish Group

16. Proposed Outputs

17. Harm Reduction: Smoke-free City • Lorna Corbin • Commissioning and Performance Manager (Public Health) • City of London Corporation • lorna.corbin@cityoflondon.gov.uk • 020 7332 1173

18. Smoke-free City Overall Programme of work • Smoke free spaces • “No if’s no butt’s” • “Quit or Cut Down” Programmes, and electronic cigarettes • Electronic Cigarettes and Level III • Advice, Information and Guidance

19. Smoke-free City Quit or Cut Down • Level II service provided by community pharmacy offering two treatment pathways; cutting down and smoking cessation • Cut Down: structured 4 week programme aiming for a decrease in cigarette use to an eventual quit • Smoking Cessation: as with other level II services, but with advisor discretion to provide a further 12 weeks of NRT to patients not ready to quit • Electronic cigarettes are offered alongside NRT for both treatment pathways

20. Smoke-free City Electronic Cigarettes • 6 month pilot in both level II and level III services • Used in conjunction with traditional smoking cessation services • Aims: • To engage with smokers we currently don’t reach • To engage with communities where smoking prevalence is highest • To raise awareness and understanding of nicotine

21. Leicester and Leicestershire Harm Reduction Project

22. What is the project?

23. How did the project come about?

24. Project Benefits

25. How much does it cost?

26. Problems or hurdles

27. What’s happening locally? • Feedback from three surveys conducted by ASH of local staff who attended the harm reduction seminars • First survey October 2013 – 105 responses • Second November 2013 – 65 responses • Third May 2014 – 61 responses • Not conclusive but does provide some insights

28. What is happening locally?

29. What is happening locally?

30. What is happening locally?

31. What is happening locally?

32. What’s happening locally?

33. What people said they’d like to do Training materials • Training for health and local authority staff • Top 10 tips for primary and secondary care publication Workplace programmes • Temporary abstinence at work with funded NRT • Temporary abstinence for staff on closed wards Targeted on priority groups • Dedicated worker to run a programme with parents at children’s centres • Target hard to reach groups • Pilot in mental health services • Program for people with long term conditions Mass media/ communications • A plotline on Corrie! • Communications campaign to give smokers information • Public awareness campaign that nicotine doesn’t cause cancer • Advice leaflets on NCPs • Market cut down to quit program • Make Stop Smoking Services ‘harm reduction friendly’ • Contribute it to a regional mass media campaign • Market safe alternatives to smoking to pregnant women • Outreach events New service model • Cut down to quit groups • Contact ‘frequent flyers’ to offer them a harm reduction approach • Develop a triage service to get people the right support • Develop self-help cut down to quit program • Behavioural support service alongside self-funded NRT Provide alternative sources of nicotine • E-cigarettes • Flood the city with NRT

34. What people say they are doing Communications • Reactive communications regarding electronic cigarettes • Developing more local, and regional, briefings for professionals on use of licensed, and unlicensed NCPs • Advise for public • We have worked with our CCGs to encourage hospital sites to sell NRT products to staff and the public to support harm reduction. • Advice on the use of E-cigarettes has been produced for both the general public and health professionals Proving alternative sources of nicotine • Longer term licensed medication for those who need it through pharmacies. • Starter packs of e-cigarettes through pharmacies. • Long term NRT use for selected clients with LTC • Commissioners are saying we can prescribe for up to 6 months where necessary for harm reduction purposes • Additional NRT provision within our community pharmacy voucher scheme • Samples of NRT to entice people to try it Temporary abstinence • Temporary abstinence for patients in hospital • Temp abstinence in hospitals and workplaces • Stop B4 the op already in place • Temporary abstinence in hospital • We are working with our mental health service providers to provide NRT for abstinence in inpatient settings Education and training • Ongoing education for stop smoking practitioners • Information for primary care • New training programme and materials to all Secondary Care staff based around the use of licensed NCP's and harm reduction options. Attendance and feedback so far has been really positive and encouraging.

35. Scottish guidance on harm reduction Stop in one step Strongest supporting evidence Greatest health benefit Stopping smoking with long term nicotine use Cut down to quit Good supporting evidence Large health benefit Smoking reduction with no intention to stop Temporary abstinence Weakest supporting evidence Uncertain health benefit

36. What people say they are doing Target groups • Local secure Mental Health unit • Discussions and training within the local prison • Working with specific populations where the harm reduction message is paramount, hopefully leading to cessation • Provision of HR by specialist cessation service if a quit has failed • Local drugs project and homeless centres • We commission what we call Level 0 work in certain local communities so that they will engage with smokers to help them to pledge to cut down or have and action plan to cut down to quit and in deprived areas this seems to help with engagement of smokers who are not quite ready to quit. Cut down to quit • Cut down to quit policy for use within the Specialist service only (not GPs and pharmacies) • Introduced a cut down to quit within all of our stop smoking service specifications • Cut down to quit for mental health clients - In patient and in the community Research • A small target to support smokers with a harm reduction approach to really test the water see how likely people are to come forward and seek support for this method. Also whether it then leads on to them quitting completely • A business plan to research local smokers and develop a marketing campaign that will reach smokers with the harm reduction message. Developing a strategy • Alliance Task and Finish group looking specifically at harm reduction and how we can maximise our work in this area

37. What’s happening locally?

38. Addressing some of the challenges for local implementation • What can we do with limited resources? • Are their activities which have limited expenditure? • Do we have to use our prescribing budgets for HR? • Can HR work be embedded into existing activity? • Can we start small to establish a business case? • How do we get messages right to ensure quitting is not undermined? • Is their existing insights work we can learn from? • Are their existing projects we can learn from? How do Stoptober and No Smoking Day do it? • Are their some messages which are common to quitting and harm reduction e.g. relative safety of licenced NCPs?

39. Addressing some of the challenges for local implementation • How can we identify appropriate measures of success? • What is success from a temporary abstinence or cut down to quit intervention? How can we measure it? • How do we measure long term replacement of smoking with licenced NCP (or unlicensed)? Is it different from normal quit? • What about electronic cigarettes? • How should services talk about them in the context of harm reduction? e.g. long term substitution, temporary abstinence, cut down to quit.