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GPs should offer NRT to smokers who refuse to quit, says NICE

GPs should offer nicotine replacement therapy (NRT) to smokers who refuse to quit in order to help them cut down the amount they smoke, according to new NICE guidance aimed at helping more people kick the habit.

The guidance emphasises that GPs should still advise patients to stop smoking in one step, but offer those who do not feel ready to quit abruptly - with the exception of pregnant women - help to cut down.

NICE recommends smokers without a quit date are offered the prescription of licensed nicotine products such as patches, gum and spray, as well as behavioural approaches including ‘schedules’ to increase intervals between cigarettes.

The guidance does not, however, cover unlicensed nicotine products, in particular electronic cigarettes, which are still under review for safety by the Medicines and Healthcare Products Regulatory Agency.

NICE says the approach may be beneficial in groups who tend to find it more difficult to quit, including those in manual occupations, people with mental health problems and those from disadvantaged groups such as the homeless and prison inmates, as well as gay, lesbian and transgender people.

But it stresses that stopping smoking completely still offers patients the best chance of quitting and the most effective way of reducing the harmful effects of smoking.

NICE previously dropped plans to introduce a ‘countdown to quit’ approach for such people, after concerns it would give the wrong message to smokers. But having reviewed evidence again, the regulator now says smokers are more likely to quit in the long term if they use NRT to cut down, even if they had no intention of quitting at first.

The guideline adds there is no evidence of any harm from taking licensed nicotine-containing products and continuing to smoke.

Professor Paul Aveyard, a GP in Solihull and professor of behavioural medicine at Oxford University who helped develop the guidance, told Pulse that the evidence showed it was cost-effective to prescribe NRT in smokers unwilling to quit.

He said: ‘It may hit prescribing budgets, although I honestly think that most people will hear this message and just go and buy their own NRT methods and not go and get prescriptions all the time. I don’t think it will be a major burden on GPs’ time or budgets.

‘But NICE’s guidance to commissioners is – think about these services, they look like they’re good value for the NHS and these are the kinds of services we should be providing.’

Dr Tim Lancaster, GP in Oxford and co-ordinating editor of the Cochrane tobacco addiction review group, said the new guidance was ‘certainly evidence-based’.

He added: ‘Obviously cessation is what we would all want but reduction is good if you can’t achieve cessation.’

But Dr Alex Bobak, a GP in Wandsworth, London and a GPSI in smoking cessation, said it was only an option for a ‘small niche’ of smokers.

He said: ‘It is only people who really won’t or can’t embark on abrupt way of quitting that you should consider for harm reduction and even harm reduction should be with a view to ultimately going for a complete quit attempt.’

‘Of course it will be more expensive than an abrupt quit as treatment will last a matter of months rather than weeks. But in the scheme of things, compared with other interventions we’re using it can be a very cost-effective approach.’

NICE – Tobacco: harm-reduction approaches to smoking

Readers' comments (10)

  • I can see this leading to a lot of complains - 'the doctors kept harping on about smoking even though I told them I didn't want to quit'

    Is NICE offering to help us draft the complaint responses and type up the letters?

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  • Is there any joined up thinking at NICE anymore? This has a cost impact upon GP prescribing budgets with probably little or no benefit. I am not burnt out just f*cked off with this sort of stupidity.

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  • If a patient doesnt want to quit then they won't and therfore I totally agree that this would be a complete waste of money. You have to be 100% committed to giving up or nothing will work and I'm talking from a position of personal experience. Give them all the Alan Carr book, 'The easy way to quit smoking'. Reading that book gave me the commitment to give up without any NRT and I was then able to pass the book on.

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  • People don't get cigarettes on prescription so why do they need NRT on prescription when it doesn't cost any more than fags?

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  • Vinci Ho

    Contenious
    But this offers some lateral thinking for a minority of patients who could not yet make up their mind to quit.
    I suppose every individual can be different.....
    Keep an open mind .......

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  • The issue here is not whether we should consider patches as an option for those who wish to cut down ( after a full discussion and listening to the patient) but whether GPs need this kind of expensive rubbish clogging up their brains.
    Why do we need to pay people to produce this rubbish and why can't we use our common sense and negotiation skills where appropriate to decide with the patient what would be sensible and most likely to work?

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  • He said: ‘It may hit prescribing budgets, although I honestly think that most people will hear this message and just go and buy their own NRT methods and not go and get prescriptions all the time. I don’t think it will be a major burden on GPs’ time or budgets.

    Professor Aveyard...... is this evidence or opinion? If you are introducing new NICE guidance I want the former and not the latter please.

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  • I, and I guess many other GPS have recommended a reducing approach for a very long time.
    Is it ethical to prescribe NRT to non commited patients, given them false expectations?
    How long is the prescription suppose to be for? Patients request paracetamol as it is free (in Wales) Will they really buy their NRT?

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  • Methadone springs into my mind

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  • Only that methadone prevents crime, helps to gain stability for the individual (who in some cases may return to employment) with a positive effect on those around ( specially children)

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