A Smoking Cessation Policy for Scotland

Appendices

Appendix 1 (Protocol for smoking cessation interventions)
Appendix 2 ('Stepped Care' approach in Scotland)
Appendix 3 (Membership of Expert Working Group)
Appendix 4 (Classification of tobacco use)
Appendix 5 (Estimated cost of making NRT available on prescription in Scotland)
Appendix 6 (Cost effectiveness of smoking cessation interventions)

Appendix One

Protocol for smoking cessation interventions

Agency for Health Care Policy and Research: protocols for smoking cessation interventions

The Agency for Health Care Policy Research in the USA has suggested a 'stepped care' approach to smoking cessation. This involves brief, low cost intervention for smokers who can stop without extensive support, moving up to provision of specialist smokers clinics for more dependent smokers. The AHCPR has recommended a set of protocols for maximising the effectiveness of smoking cessation interventions as follows:

Every person who smokes should be offered smoking cessation treatment at every office visit.
Clinicians should ask and record the tobacco-use status of every patient
Cessation treatments even as brief as 3 minutes a visit are effective.
More intensive treatment is more effective in producing long-term abstinence from tobacco.
Nicotine Replacement therapy, clinician-delivered social support and skills training are particularly effective components of smoking cessation treatment
Health care systems should make institutional changes that result in the systematic identification of, and intervention with, all tobacco users at every visit.

Ref: Fiore MC, Bailey WC, Cohen SJ et. al. Smoking Cessation. Clinical Practice Guideline No.18. Rockville, MD: US Department of Health and Human Services Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 96-0692. April 1996

Appendix Two

"Stepped Care" approach in Scotland

When discussing smoking cessation interventions it is important to consider which type of smoker the intervention is best targeted at, in terms of level of motivation to stop and degree of addiction to tobacco.

An effective stepped care approach could include the following components:

The provision of health education and information designed to increase motivation to quit, backed up as appropriate with support for quitting provided through, for example, direct response mass media campaigns and helplines such as Smokeline. These efforts should be geared primarily towards the needs of sections of the population not yet aware of the information provided and those with little desire to quit.
Brief advice to stop smoking from health professionals and primary care workers. GPs in particular should take the time to give a brief period of advice on quitting to all their patients who smoke. After initial advice from a doctor there should be follow up support either from a GP or nurse and provision of NRT if necessary.
Nicotine Replacement Therapy should be offered to smokers who are intent on stopping plus a follow-up appointment. The transdermal patch is the most convenient preparation; the 4mg gum or nasal spray may be more effective in the most highly nicotine dependent smokers.
Intensive treatments in a specialist clinic should be available to provide intensive support with NRT to the more highly addicted smokers. Well-run, specialist smokers' clinics making appropriate use of NRTs can improve the chances of stopping smoking between three and four-fold.

(Adapted from Foulds J. (1996) Strategies for smoking cessation. British Medical Bulletin; 52 (1) 157-173.)

Appendix Three

Participants at ASH Scotland/HEBS Expert Working Group

Dr. Amanda Amos Senior Lecturer, Health Promotion
Public Health, Edinburgh University

Ms. Yvonne Bostock Consultant
Health & Health Research

Dr. Candace Currie Senior Research Fellow
Research Unit in Health & Behavioural Change

Ms. Sheila Duffy Information & Resource Development Manager
ASH Scotland

Ms. Sally Haw Research Specialist, Substance Misuse
Health Education Board for Scotland

Dr. James Inglis Consultant in Public Health Medicine
Health Education Board for Scotland

Ms. Irene Keltie Development Worker
Wester Hailes Health Project

Dr. Scott Lennox Clinical Research Fellow
Forresterhill Health Centre

Dr. John Logan Senior Registrar in Public Health Medicine
Health Education Board for Scotland

Mrs. Maureen Moore Chief Executive
ASH Scotland

Dr. Martin Raw Hon. Senior Lecturer in Public Health
King's College School of Medicine

Mrs. Wendy Ugolini Press & Campaigns Manager
ASH Scotland

OBSERVERS
Ms. Mary Cuthbert Smoking Action Manager
Drugs, Alcohol & Tobacco Policy Team, Scottish Office

Mr. Drew Peden Alcohol Action Manager
Drugs, Alcohol & Tobacco Policy Team, Scottish Office

Appendix Four

ICD 10 classification of tobacco use

(ICD 10) categorises disorders that are attributable to the use of psychoactive substances. Category F17 covers Mental and behavioural disorders due to the use of tobacco. Three fourth-character subdivisions are relevant to tobacco use.

F17.1 Harmful use
A pattern of psychoactive substance use that is damaging to health. The damage may be physical or mental.

F17.2 Dependence syndrome
A cluster of behavioural, cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state.

F17.3 Withdrawal state
A group of symptoms of variable clustering and severity occurring on absolute or relative withdrawal of a psychoactive substance after persistent use of that substance. The onset and course of the withdrawal state are time-limited and are related to the type of psychoactive substance and the dose being used immediately before cessation or reduction in use.

Appendix Five

Estimated cost of making N. R. T. available on the NHS in Scotland

In Scotland 35% of adults smoke cigarettes, giving an adult smoking population of 1.4 million.

The NHS cost of NRT products (gum/patch) is estimated to be �8 per week, and a course is of three weeks duration, then the NHS cost of a completed course of NRT is �24.

Thirteen percent of smokers who attempt smoking cessation using NRT are successful. Therefore one in eight complete a successful course of NRT and 7 unsuccessful attempts are concluded after a weeks treatment. The estimated cost to the NHS is �80 per successful quitter.

The table below gives a range of estimates of the cost of providing NRT on the NHS based on the assumptions outlined above and three levels of demand per annum - 5%, 10% and 15% of adult smokers.

Estimated Cost of Making Nicotine Replacement Therapy Available on the NHS
No of attempts at NRT	5% Smokersn = 70,000	10% smokersn = 140,000	15% smokersn = 210,000
Estimated cost per annum	�728,000	�1,456,000	�2,184,000
Number of quitters per annum	9,100	18,200	27,300

Appendix Six

Cost effectiveness of smoking cessation interventions

Cost per life year gained for the local NHS, smokers and both combined
	NHS	SMOKERS	BOTH
Primary health care interventions:
Brief advice	�81	�13	�94
Additional cost per life on top of brief advice:
Brief counselling	�415	�130	�545
Nicotine gum	�37	�426	�463
Community interventions:
Local No Smoking Day activities	�21	n.a.	�21
Broader community wide campaigns with:
- 100% reach and 0.50% effectiveness	�54	n.a.	�54
- 100% reach and 0.10% effectiveness	�271	n.a.	�271
- 100% reach and 0.05% effectiveness	�541	n.a.	�541
Quit and Win competition with:
- average cost & participation	�522	n.a.	�522
- low cost & participation	�543	n.a.	�543
- high cost & participation	�711	n.a.	�711

(Taken from Buck D, Godfrey C, Parrott S & Raw M. (1997) Cost effectiveness of smoking cessation interventions, HEA, London)

Summary
Introduction
Nicotine
Smoking Cessation Interventions
Approaches in Different Settings
Cost Effectiveness
Inequalities in Tobacco Use
Other Issues
Conclusions
Recommendations
References
Appendices