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Complete Summary

GUIDELINE TITLE

Workplace health promotion: how to help employees to stop smoking.

BIBLIOGRAPHIC SOURCE(S)

  • National Institute for Health and Clinical Excellence (NICE). Workplace health promotion: how to help employees to stop smoking. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Apr. 43 p. (Public health intervention guidance; no. 5). [22 references]

GUIDELINE STATUS

This is the current release of the guideline.

** REGULATORY ALERT **

FDA WARNING/REGULATORY ALERT

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • May 2, 2007, Antidepressant drugs: Update to the existing black box warning on the prescribing information on all antidepressant medications to include warnings about the increased risks of suicidal thinking and behavior in young adults ages 18 to 24 years old during the first one to two months of treatment.

COMPLETE SUMMARY CONTENT

 ** REGULATORY ALERT **
 SCOPE
 METHODOLOGY - including Rating Scheme and Cost Analysis
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
 IMPLEMENTATION OF THE GUIDELINE
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

SCOPE

DISEASE/CONDITION(S)

Smoking

GUIDELINE CATEGORY

Assessment of Therapeutic Effectiveness
Counseling
Prevention

CLINICAL SPECIALTY

Family Practice
Internal Medicine
Nursing
Preventive Medicine
Psychiatry
Psychology

INTENDED USERS

Advanced Practice Nurses
Allied Health Personnel
Hospitals
Nurses
Patients
Pharmacists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Social Workers
Substance Use Disorders Treatment Providers

GUIDELINE OBJECTIVE(S)

To assist National Health Service (NHS) and non-NHS professionals and employers who have a role in – or responsibility for – supporting and encouraging employees who smoke to quit

TARGET POPULATION

Employees who smoke

INTERVENTIONS AND PRACTICES CONSIDERED

  1. Brief interventions in health and community care, involving opportunistic advice, discussion, negotiation, or encouragement
    • Simple opportunistic advice to stop
    • An assessment of the patient's commitment to quit
    • An offer of pharmacotherapy and/or behavioural support
    • Provision of self-help material and referral to more intensive support such as the National Health Service Stop Smoking Services
  2. Availability of smoking cessation advice and support for employers (with special emphasis on efforts targeting enterprises where a high proportion of employees are on low pay, from a disadvantaged background and/or are heavy smokers)
  3. Availability of information by employers of smoking cessation policies, practices, support services and accessibility of services

MAJOR OUTCOMES CONSIDERED

  • Smoking cessation rate
  • Non-validated and validated smoking status
  • Cost-effectiveness

METHODOLOGY

METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Key Questions

Key questions were established as part of the scope. They formed the starting point for the reviews of evidence and facilitated the development of recommendations by the Public Health Interventions Advisory Committee (PHIAC). Refer to appendix D in the original guideline document for a list of key questions.

Reviewing the Evidence of Effectiveness

A review of effectiveness was conducted.

Identifying the Evidence

The following databases were searched in four stages, as follows.

Stage 1

The search for systematic reviews and reviews was undertaken in the following databases for the years 1990–2006: Cochrane database of systematic reviews; DARE; National Research Register; Health Technology Assessment Database; SIGN Guidelines; National Guideline Clearinghouse; HSTAT; TRIP; Medline (1966–May 2006); Embase (1974–2006); CINAHL (1982–2006); British Nursing Index (1994–2006); PsycINFO (1806–2006); DH-Data (1983–2006); King's Fund (1979–2006).

Stage 2

The search for other publications was undertaken in the following databases: Medline (1966–May 2006); Embase (1974–2006); CINAHL (1982–2006); British Nursing Index (1994–2006); PsycINFO (1806–2006); DH-Data (1983–2006); King's Fund (1979–2006); CENTRAL (2006/2).

Stage 3

A further search of Medline was undertaken for abstracts (as well as titles) of all publications.

Stage 4

A search was undertaken of the following websites to identify any additional reports and documents of relevance:

Further details of the databases, search terms and strategies are included in the review report.

Selection Criteria

Studies were included if they covered:

  • People who smoke aged 16 and over
  • Workplace smoking cessation interventions delivered either at work or externally

Studies were excluded if they described workplace health improvement programmes that did not include a smoking-related component.

Economic Appraisal

The economic appraisal consisted of a review of economic evaluations and a cost-effectiveness analysis.

Review of Economic Evaluations

A systematic search was carried out on the National Health Service Economic Evaluation Database (NHS EED) database and the Centre for Reviews and Dissemination (CRD) internal database. This was supplemented by material found in the effectiveness and cost-effectiveness reviews undertaken for the National Institute for Health and Clinical Excellence (NICE) smoking cessation programme (under development).

The criteria for inclusion in the review were as follows:

  • Studies included a specific intervention to assist smoking cessation
  • The study population was smoking at the start of the study (unless drawn from a general population)
  • Studies reported on both the cost and effectiveness of the smoking cessation intervention (although cost and effectiveness was not necessarily combined into a single cost-effectiveness ratio)

Ten studies met the inclusion criteria. These were assessed for their methodological rigour and quality using the critical appraisers' checklists provided in Appendix B of the "Methods for development of NICE public health guidance" (see "Availability of Companion Documents" field in this summary). Each study was categorised by study type and graded using a code (++), (+) or (-), based on the potential sources of bias.

NUMBER OF SOURCE DOCUMENTS

Not stated

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Study Type

1 Meta-analyses, systematic reviews of randomised clinical trials (RCTs) or RCTs (including cluster RCTs).

2 Systematic reviews of, or individual, non-randomised controlled trials, case-control studies, cohort studies, controlled before-and-after (CBA) studies, interrupted time series studies, correlation studies.

3 Non-analytical studies (for example, case reports, case series).

4 Expert opinion, formal consensus.

Study Quality

++ All or most of the criteria have been fulfilled. Where they have not been fulfilled the conclusions are thought very unlikely to alter.

+ Some criteria have been fulfilled. Those criteria that have not been fulfilled or not adequately described are thought unlikely to alter the conclusions.

– Few or no criteria fulfilled. The conclusions of the study are thought likely or very likely to alter.

METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Quality Appraisal

Included papers were assessed for methodological rigour and quality using the National Institute for Health and Clinical Excellence (NICE) methodology checklist, as set out in the NICE technical manual "Methods for development of NICE public health guidance" (see "Availability of Companion Documents" field). Each study was described by study type (classified 1–4) and graded (++, +, -) to reflect the risk of potential bias arising from its design and execution.

Summarising the Evidence and Making Evidence Statements

The review data was summarised in evidence tables (see full reviews and synopsis). The findings from the review were synthesised and used as the basis for a number of evidence statements relating to each question. The evidence statements reflect the strength (quantity, type and quality) of the evidence and its applicability to the populations and settings in the scope.

Economic Appraisal

Studies were assessed for their methodological rigour and quality using the critical appraisers' checklists provided in appendix B of the "Methods for development of NICE public health guidance" (see "Availability of Companion Documents" field). Each study was categorised by study type and graded using a code (++), (+) or (-), based on the potential sources of bias.

Cost-effectiveness Analysis

An economic model was constructed to incorporate data from the reviews of effectiveness and cost effectiveness. The results are reported in: "Cost effectiveness of interventions for smoking cessation" and "Cost impact analysis of workplace-based interventions for smoking cessation" These reports are available on the NICE website at www.nice.org.uk/PHI005

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Informal Consensus

DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

How Public Health Interventions Advisor Committee (PHIAC) Formulated the Recommendations

At its meetings in May 2006 and September 2006 PHIAC considered the evidence of effectiveness and cost effectiveness. In addition, at its meeting in December 2006, it considered comments from stakeholders on the evidence, and in February comments from stakeholders on the draft guidance.

PHIAC developed draft recommendations through informal consensus, based on the following criteria.

  • Strength (quality and quantity) of evidence of effectiveness and its applicability to the populations/settings referred to in the scope.
  • Effect size and potential impact on population health and/or reducing inequalities in health.
  • Cost effectiveness (for the National Health Service and other public sector organisations).
  • Balance of risks and benefits.
  • Ease of implementation and the anticipated extent of change in practice that would be required.

PHIAC also considered whether a recommendation should only be implemented as part of a research programme where evidence was lacking.

Where possible, recommendations were linked to an evidence statement(s) (see Appendix A in the original guideline document for details). Where a recommendation was inferred from the evidence, this was indicated by the reference 'IDE' (inference derived from the evidence).

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

COST ANALYSIS

Summary of Findings from the Literature Review

Overall, there is limited information on the cost effectiveness of workplace smoking cessation interventions, but the studies that were identified in the review suggest that they are cost effective.

Summary of Findings from Modelling the Health Benefits

The model aimed to estimate the cost effectiveness of smoking cessation interventions delivered in the workplace. These included:

  • No intervention
  • Brief advice (BA)
  • BA plus self-help material (SHM)
  • BA plus SHM plus advice for nicotine replacement therapy (NRT)
  • BA plus SHM plus NRT plus specialist smoking service
  • Bupropion plus less intensive counselling (LIC)
  • Bupropion plus more intensive counselling (MIC)
  • Nicotine patch
  • Nicotine patch plus group counselling
  • Nicotine patch plus individual counselling
  • Nicotine patch plus pharmacist consultation
  • Nicotine patch plus pharmacist consultation plus behavioural program

All interventions led to a reduction in the number of people who smoke, fewer comorbidities and more years of good health (QALYs) compared to 'no intervention.'

Summary of Findings from Modelling the Net Financial Benefit to Employers

All interventions reduced the number of employees who smoke, leading to increased productivity compared to 'no intervention'. Cessation rates were directly linked to productivity: a high cessation rate led to lower associated productivity losses.

The net financial benefit for employers was calculated by subtracting the cost of the intervention from the productivity benefits. Most interventions begin to produce a net financial benefit after 2 years. Some of the cheaper interventions lead to a net financial benefit after 1 year.

Full details of the surveys of current practice and reviews of cost effectiveness and modelling can be found on the National Institute for Health and Clinical Excellence (NICE) website (www.nice.org.uk/PHI005).

METHOD OF GUIDELINE VALIDATION

External Peer Review
Internal Peer Review

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The draft guidance, including the recommendations, was released for consultation in December 2006. The guidance was signed off by the National Institute for Health and Clinical Excellence (NICE) Guidance Executive in March 2007.

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

This document constitutes the Institute's formal guidance on how to encourage and support employees to stop smoking.

The recommendations in this section are presented without any reference to evidence statements. Appendix A in the original guideline document repeats the recommendations and lists their linked evidence statements.

Recommendation 1

Who should take action?

Employers

What action should they take?

  • Publicise the interventions identified in this guidance and make information on local stop smoking support services widely available at work. This information should include details on the type of help available, when and where, and how to access the services.
  • Be responsive to individual needs and preferences. Where feasible, and where there is sufficient demand, provide on-site stop smoking support.
  • Allow staff to attend smoking cessation services during working hours without loss of pay.
  • Develop a smoking cessation policy in collaboration with staff and their representatives as one element of an overall smoke-free workplace policy.

Recommendation 2

Who should take action?

Employees who want to stop smoking

What action should they take?

Contact local smoking cessation services, such as the NHS Stop Smoking Services, for information, advice and support.

Recommendation 3

Who should take action?

Employees and their representatives

What action should they take?

Encourage employers to provide advice, guidance and support to help employees who want to stop smoking.

Recommendation 4

Who should take action?

All those offering smoking cessation services including the NHS, independent or commercial organisations and employers

What action should they take?

Recommendation 5

Who should take action?

Managers of NHS Stop Smoking Services

What action should they take?

  • Offer support to employers who want to help their employees to stop smoking. Where appropriate and feasible, provide support on the employer's premises.
  • If initial demand exceeds the resources available, focus on the following:
    • Small and medium-sized enterprises (SMEs)
    • Enterprises where a high proportion of employees are on low pay
    • Enterprises where a high proportion of employees are from a disadvantaged background
    • Enterprises where a high proportion of employees are heavy smokers

Recommendation 6

Who should take action?

Strategic health authorities and primary care trusts.

What action should they take?

Ensure local NHS Stop Smoking Services are able to respond to fluctuations in demand, particularly before and after implementation of smoke-free legislation.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type and quality of supporting evidence is identified and graded for each recommendation (see Appendix A in the original guideline document).

BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

Reducing levels of smoking among employees will help reduce some illnesses and conditions (such as cardiovascular disease and respiratory diseases) that are important causes of sickness absence. This will result in improved productivity and less costs for employers.

POTENTIAL HARMS

Not stated

IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

The Healthcare Commission assesses the performance of National Health Service (NHS) organisations in meeting core and developmental standards set by the Department of Health (DH) in "Standards for Better Health" issued in July 2004 and updated in 2006. The implementation of National Institute for Health and Clinical Excellence (NICE) public health guidance will help organisations meet the standards in the public health (seventh) domain in "Standards for Better Health." In addition, implementation of NICE public health guidance will help meet the health inequalities target as set out in "The NHS in England: the operating framework for 2006/7."

NICE has developed tools to help organisations implement this guidance (see "Availability of Companion Documents" field).

  • Costing tools:
    • Business case for supporting employees to quit smoking.
  • Other tools:
    • A slide set for smoking cessation services and employers highlighting key messages for local discussion
    • Information sheet for employers explaining how NICE guidance can support compliance with smoke-free legislation
    • Practical advice for smoking cessation services on how to implement the guidance and details of national initiatives that can provide support.

IMPLEMENTATION TOOLS

INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Staying Healthy

IOM DOMAIN

Effectiveness
Patient-centeredness

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • National Institute for Health and Clinical Excellence (NICE). Workplace health promotion: how to help employees to stop smoking. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Apr. 43 p. (Public health intervention guidance; no. 5). [22 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2007 Apr

GUIDELINE DEVELOPER(S)

National Institute for Health and Clinical Excellence (NICE) - National Government Agency [Non-U.S.]

SOURCE(S) OF FUNDING

National Institute for Health and Clinical Excellence (NICE)

GUIDELINE COMMITTEE

NICE Project Team
Public Health Interventions Advisory Committee (PHIAC)

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

NICE Project Team Members: Professor Mike Kelly, CPHE Director; Tricia Younger, Associate Director; Dr Lesley Owen, Lead Analyst; Patti White, Analyst; Dr Hugo Crombie, Analyst; Dr Alastair Fischer, Health Economics Adviser

Public Health Interventions Advisory Committee (PHIAC) Members: Mrs Cheryll Adams, Professional Officer for Research and Practice Development with the Community Practitioners' and Health Visitors' Association (CPHVA); Professor Sue Atkinson, CBE Independent Consultant and Visiting Professor in the Department of Epidemiology and Public Health, University College London; Professor Michael Bury, Emeritus Professor of Sociology at the University of London and Honorary Professor of Sociology at the University of Kent; Professor Simon Capewell, Chair of Clinical Epidemiology, University of Liverpool; Professor K K Cheng, Professor of Epidemiology, University of Birmingham; Dr Richard Cookson, Senior Lecturer, Department of Social Policy and Social Work, University of York; Mr Philip Cutler, Forums Support Manager, Bradford Alliance on Community Care; Professor Brian Ferguson, Director of the Yorkshire and Humber Public Health Observatory; Professor Ruth Hall, Regional Director, Health Protection Agency, South West; Ms Amanda Hoey, Director, Consumer Health Consulting Limited; Mr Andrew Hopkin, Senior Assistant Director for Derby City Council; Dr Ann Hoskins, Deputy Regional Director of Public Health for NHS North West; Ms Muriel James, Secretary for the Northampton Healthy Communities Collaborative and the King Edward Road Surgery Patient Participation Group; Professor David R Jones, Professor of Medical Statistics in the Department of Health Sciences, University of Leicester; Dr Matt Kearney, General Practitioner, Castlefields, Runcorn and GP Public Health Practitioner, Knowsley; Ms Valerie King, Designated Nurse for Looked After Children for Northampton PCT, Daventry and South Northants PCT and Northampton General Hospital. Public Health Skills Development Nurse for Northampton PCT; Dr Catherine Law (Chair) Reader in Children's Health, Institute of Child Health, University College London; Ms Sharon McAteer, Health Promotion Manager, Halton PCT; Professor Klim McPherson, Visiting Professor of Public Health Epidemiology, Department of Obstetrics and Gynaecology, University of Oxford; Professor Susan Michie, Professor of Health Psychology, BPS Centre for Outcomes Research & Effectiveness, University College London; Dr Mike Owen, General Practitioner, William Budd Health Centre, Bristol; Ms Jane Putsey, Lay Representative. Chair of Trustees of the Breastfeeding Network; Dr Mike Rayner, Director of British Heart Foundation Health Promotion Research Group, Department of Public Health, University of Oxford; Mr Dale Robinson, Chief Environmental Health Officer, South Cambridgeshire District Council; Professor Mark Sculpher, Professor of Health Economics at the Centre for Economics (CHE), University of York; Dr David Sloan, Retired Director of Public Health; Dr Dagmar Zeuner, Consultant in Public Health, Islington PCT

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

All members of the Public Health Interventions Advisory Committee are required to make an oral declaration all potential conflicts of interest at the start of the consideration of each public health intervention appraisal. These declarations will be minuted and published on the National Institute for Health and Clinical Excellence (NICE) website.

Members are required to provide in writing an annual statement of current conflicts of interests, in accordance with the Institute's policy and procedures.

Potential members of the Public Health Programme Development Groups (PDG), and any individuals having direct input into the guidance (including expert peer reviewers), are required to provide a formal written declaration of personal interests. A standard form has been developed for this purpose which also includes the Institute's standard policy for declaring interests. This declaration of interest form should be completed before any decision about the involvement of an individual is taken.

Any changes to a Group member's declared conflicts of interests should also be recorded at the start of each PDG meeting. The PDG Chair should determine whether these interests are significant.  If a member of the PDG has a possible conflict of interest with only a limited part of the guidance development or recommendations, that member may continue to be involved in the overall process but should withdraw from involvement in the area of possible conflict. This action should be documented and be open to external review. If it is considered that an interest is significant in that it could impair the individual's objectivity throughout the development of public health guidance, he or she should not be invited to join the group.

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

  • Workplace interventions to promote smoking cessation. Quick reference guide. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Apr. 6 p. (Public Health Intervention Guidance 5). Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site.
  • Costing template: workplace health promotion: how to help employees to stop smoking. Full business case. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Apr. Various p. (Public Health Intervention Guidance 5). Available in Portable Document Format (PDF) from the NICE Web site.
  • Costing template: workplace health promotion: how to help employees to stop smoking. Simplified business case. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Apr. Various p. (Public Health Intervention Guidance 5). Available in Portable Document Format (PDF) from the NICE Web site.
  • Costing template: workplace health promotion: how to help employees to stop smoking. Summary business case. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Apr. 6 p. (Public Health Intervention Guidance 5). Available in Portable Document Format (PDF) from the NICE Web site.
  • Costing template: stop smoking legislation. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Apr. Various p. (Public Health Intervention Guidance 5). Available in Portable Document Format (PDF) from the NICE Web site.
  • Information for employers – what you can do to encourage your employees to stop smoking. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Apr. 1 p. (Public Health Intervention Guidance 5). Available in Portable Document Format (PDF) from the NICE Web site.
  • Slide set: workplace interventions to promote smoking cessation. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Apr. 18 p. (Public Health Intervention Guidance 5). Available in Portable Document Format (PDF) from the NICE Web site.
  • Implementation advice: workplace interventions to promote smoking cessation. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Apr. 19 p. (Public Health Intervention Guidance 5). Available in Portable Document Format (PDF) from the NICE Web site.
  • Audit criteria: workplace health promotion: how to help employees to stop smoking. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Apr. 10 p. (Public Health Intervention Guidance 5). Available in Portable Document Format (PDF) from the NICE Web site.
  • Methods for development of NICE public health guidance. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Oct. 131 p. Available in Portable Document Format (PDF) from the NICE Web site.

Print copies: Available from the National Health Service (NHS) Response Line 0870 1555 455. ref: N1188. 11 Strand, London, WC2N 5HR.

PATIENT RESOURCES

None available

NGC STATUS

This summary was completed by ECRI on June 20, 2007. The information was verified by the guideline developer on July 16, 2007. This summary was updated by ECRI Institute on October 31, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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