If you can’t quit smoking in one go, what are your options? In England it appears that hard core smokers may be offered an alternative route that starts with “harm reduction” rather than quitting in one step. A draft guidance based on this approach was launched this week for public consultation.

Although over the last 50 years or so there has been a dramatic reduction in the numbers who smoke, there remains a “hard core” of people who find it hard to quit, as well as those who don’t want to.

Now NICE (the National Institute for Health and Clinical Excellence), the independent body that in England responsible for providing national guidance and standard on matters of health, is putting out a draft guideline titled “Tobacco: harm-reduction approaches to smoking” for public consultation that seeks to help those who can’t quit smoking in one step.

Professor Mike Kelly, Director of the NICE Centre for Public Health Excellence, says in a statement:

“This draft NICE guidance will, once finalised, be useful in setting out how different harm reduction options can help tackle tobacco use for individuals who smoke.”

“Smoking tobacco is responsible for over 79,000 deaths in England each year and children’s vulnerability to second-hand smoke is well documented. If you are a smoker, quitting smoking is the best way to improve health, and quitting in one step is most likely to be successful. However some people – particularly those who are highly dependent on smoking – may not feel able (or don’t want) to do this,” says Kelly.

The guidance covers a number of harm reduction options (aimed at reducing harms to both to the smoker and others) as a route to quitting, including:

  • Quit smoking in one step with the aid of one or more licensed nicotine-based products, and continue to use such products as a substitute, possibly indefinitely.

  • Cut down as a step to quitting, with the aim of stopping altogether within a few months. Achieve this by smoking fewer cigarettes or inhaling or smoking less of each cigarette. Do this with or without the aid of one or more licensed nicotine-containing products.

  • Smoke less: either inhale less, smoke less of each cigarette, with or without the aid of licensed products.

  • Give up for a while, with or without the aid of licensed nicotine-based products, for particular occasions or settings, for instance at home or in the workplace, or in environments where smoking is not allowed (NICE cites prisons and secure mental health facilities as examples of the latter).

One in five adults living in England is a smoker. Among 20 to 34-year-olds this figure is more than one in four.

Estimates suggest the cost to the NHS in England of treating smoking-related illnesses is £2.7 billion a year. If you include loss of productivity, the overall burden is estimated to be over £13 billion a year.

Smoking harms health because tobacco smoke contains toxins and cancer-causing chemicals: it is not the nicotine that causes the damage. However, nicotine is addictive, which is why so many smokers find it hard to quit.

More than two thirds of smokers say they would like to quit.

Kelly says:

“Harm reduction approaches provide an alternative choice, and are more successful when used with licensed nicotine-containing products. Methods such as ‘cutting down to quit’ may appeal to people who feel unable to quit in one step. ‘Smoking less’ is an option for those who are not interested in quitting smoking, although the health benefits are not clear. However, for some people this can kick-start a gradual change in behaviour that eventually leads them to quit smoking.”

The draft guidance also says health professionals should advise smokers seeking to cut down as a way to quit, that it is easier to do so when they use nicotine-containing products.

They should also reassure them that such products are a safe and effective way to reduce the harm from cigarettes, and that studies show nicotine replacement therapy (NRT) products are safe for up to 5 years of use.

Advisers and health professionals should offer NRT products on prescription to people who smoke, as part of a harm-reduction strategy, says the guidance.

The guidance also recommends smokers be offered all types of NRT, either singly or in combination, according to the individual’s preference and level of dependence.

For example, patches could be offered together with gum or lozenges. People should also be advised that using more than one product is more likely to be successful particularly for more dependent smokers.

“Whatever approach people wish to try, they should be advised that there are no circumstances when it is safer to smoke than to use NRT products and experts believe that lifetime use of NRT will be considerably less harmful than smoking,” says Kelly, adding that the hope is the guidance will:

“… also raise wider awareness of the important role of licensed nicotine containing products such as nicotine replacement therapies, in helping people cut down, and then ideally stop using tobacco.”

The draft guidance will be open for public consultation from 24 October until 19 December.

Click here for further information on the consultation.

Written by Catharine Paddock PhD