HIQA advises Minister that interventions to help people quit smoking not only work, but are good value for money
The Health Information and Quality Authority (HIQA) has advised the Minister for Health Simon Harris TD that investing in interventions to help people quit smoking is effective and provides good value for money.
HIQA’s health technology assessment (HTA) is the first ever analysis carried out to compare the cost-effectiveness of alternative mixes of smoking cessation interventions with an existing standard of care, and the first assessment in the EU to examine the cost-effectiveness of e-cigarettes as an intervention to help people quit smoking. The report found that all interventions are effective at helping people quit smoking, and are cost-effective when compared with unassisted quitting.
HIQA’s Director of Health Technology Assessment Dr Máirín Ryan said: “Smoking is a major public health problem in Ireland. One in five deaths each year is due to tobacco smoke. There are approximately 820,000 smokers in Ireland, with half making at least one quit attempt each year. Yearly expenditure on smoking cessation activity is estimated to be over €40 million. This HTA has found that providing these interventions to help people quit smoking not only works, but is good value for money.”
“Today’s Health technology assessment of smoking cessation interventions recommends using varenicline (either alone or in combination with nicotine replacement therapy [NRT]) for smokers wishing to use some type of pharmacological support in their attempt to quit.”
Dr Máirín Ryan said: “The Health Service Executive (HSE) should seek to increase the uptake of varenicline, either alone or in combination with NRT (nicotine patches), among smokers who wish to use pharmacological support in their quit attempt. Using varenicline alongside NRT is more than three and half times as effective as using no active medication. However, this is a relatively new combination of interventions, and any potential implications of widespread uptake need to be considered as part of the development of clinical practice guidelines and national health policy.”
Almost one in three people in Ireland use e-cigarettes in their attempt to quit smoking. Despite some promising results, HIQA determined that there was not enough evidence at present to reliably demonstrate their effectiveness as an aid to smoking cessation.
Dr Máirín Ryan continued: “HIQA advises the Minister to await the results of ongoing trials before deciding whether to recommend e-cigarettes. A decision to advocate e-cigarette use should take into consideration any additional information on the long-term safety of e-cigarettes use, and any emerging data in relation to concerns about the social normalisation of e-cigarettes leading to increased uptake among people who have never smoked, or later migration to tobacco cigarettes.”
The report found that behavioural interventions, such as counselling and group behaviour therapy, are also effective in helping smokers to quit compared to quitting with minimal help. As pharmacological therapies are not acceptable to everyone, HIQA says it is important that behavioural interventions continue to be provided. The effectiveness of pharmacological therapies can be further improved when provided in combination with a behavioural intervention.
Dr Máirín Ryan said: “The HTA also found that pregnant women who smoke should be offered a psychosocial intervention in the first instance. There is substantial evidence to support the effectiveness of counselling for this cohort of the population. While there is limited evidence for smokers who attend specialist secondary mental health services, high-intensity interventions that combine pharmacotherapy and behavioural support have been shown to improve quit outcomes. However, further research on the effectiveness of smoking cessation interventions in this population is needed.”
The evidence, Health technology assessment of smoking cessation interventions, has been approved by the HIQA Board and presented as advice to the Minister for Health.
The report, including a plain language summary, is available at www.hiqa.ie.
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Notes to the Editor
- HIQA is the statutory organisation in Ireland with responsibility to carry out national health technology assessments (HTAs) and to develop guidelines for the conduct of HTAs across our healthcare system.
- Following a request from the Department of Health, HIQA assessed the evidence for interventions that aid with quitting smoking to inform policy decisions about improving the provision of these services and to underpin a planned national clinical guideline on smoking cessation in Ireland.
- Approximately 20.5% of deaths each year can be attributed to smoking, including deaths due to second-hand smoke.
- According to data from the Healthy Ireland survey 2015, half of smokers attempting to quit smoking in Ireland do so unaided. A further 29% of smokers try to quit using e-cigarettes as a cessation aid. Approximately 21% of quit attempts are made using some form of pharmacotherapy (for example, NRT and varenicline).
- A draft HTA was launched for a period of public consultation between 5 January 2017 and 3 February 2017, to provide all interested parties an opportunity to comment on the report before it was finalised. The public consultation received 48 submissions; 13 from individual respondents and 35 on behalf of organisations. Feedback relating to e-cigarettes accounted for half of all comments received.
- Varenicline is a prescription-only medication which helps people to stop smoking by reducing withdrawal symptoms and reducing the satisfaction that can be gained from smoking.
- Nicotine replacement therapy (NRT) includes nicotine gum, patches, inhalers, intranasal and oral sprays, and tablets.
- Varenicline was found to be the most effective single pharmacotherapy; more than two and half times as effective as placebo. Varenicline with NRT was the most effective dual therapy; more than three and half times as effective as placebo. Combination NRT was more effective than a single form of NRT alone. E-cigarettes were twice as effective as placebo; however, this estimate was based on only two trials including a relatively small number of participants.
- A budget impact analysis found that maximising the use of combination varenicline and NRT would be associated with an average increase of approximately €7 million in the annual cost of providing smoking cessation interventions in Ireland.
- Increasing the use of combination varenicline and NRT will place additional demands on general practitioner (GP) or nurse prescriber services. In the event that use of this intervention reaches plausible maximum levels, the number of prescriptions required could increase by over 50%.
- Smokers who are users of secondary mental health services typically include patients with psychotic disorders, schizophrenia or schizoaffective disorder, current depression or bipolar disorder. Secondary mental health services include general hospital psychiatric units, psychiatric hospitals and independent or private charitable centres.
- Healthcare professionals are trained in the provision of brief advice for smoking cessation, and the need to quit smoking is widely publicised. Minimal intervention in the form of brief advice or the provision of written materials was assumed to form part of the standard of care for smokers making a quit attempt.