How can stop smoking services attract people from ethnic minorities? NICE guidance may offer the answer, writes Rosie Cameron

Reaching minority ethnic and socio-economically disadvantaged communities is one of the main recommendations in the National Institute for Health and Clinical Excellence guidance on provision of smoking cessation services. But how to effectively target these groups may be one of the biggest challenges.

Dr Paul Aveyard of Birmingham University's department of primary care and general practice says evidence for how to do this may not be conclusive, making it hard to know what to do.

"It's something people agonise about: minority groups are different and the reasons why they come forward are different. Knowing how to get people to use it and to make contact may be an issue," he says. "For example, Muslim smokers feel they must stop smoking by willpower alone rather than getting help."

Dr Aveyard stresses that people, including clinicians, need to be convinced of the value of the services in order to use them. He says smoking is not necessarily brought up in all consultations, and this needs to be addressed.

Proven interventions

NICE guidance on smoking cessation services was published in February. It lists four top recommendations for implementation. These include determining the prevalence of tobacco use locally, targeting specific groups of smokers and offering a range of interventions that are proven to help people stop smoking (see box).

This means behavioural counselling, group therapy, pharmacotherapy or a combination of interventions that have proved effective, delivered by appropriately trained practitioners.

Commissioners and managers should ensure that training and continuing professional development are available for all those providing smoking cessation advice and support. Also, services should be tailored to the needs of specific groups (ethnic minorities, disadvantaged groups) and where possible, provided in the language chosen by the client. The guidance says media campaigns can be used to encourage quit attempts, and consideration should be given to targeting low income and ethnic minority groups in such campaigns, to address inequalities.

NICE also states that realistic performance targets should be set, reflecting local demographics. Services should aim to treat at least 5 per cent of those who smoke or use tobacco, and aim for a success rate of at least 35 per cent at four weeks, as validated by a carbon monoxide monitor reading of less than 10pm.

Meeting targets

Dr Aveyard believes targets may be met by treating less dependent smokers. He says that at first, smoking cessation services emphasised group-based therapy, but most is now delivered by generalists, targeting less dependent smokers: "More dependent smokers are harder to treat. Primary care trusts are focusing on more generalist provision, which is probably a mistake." He also says stringent monitoring is crucial to ensure success: "Lots of people pass through the monitoring who don't meet the definition of success. If you don't smoke that day, you meet your CO [carbon monoxide] monitoring. It comes down to people being honest and practitioners being rigorous." He adds that the NHS Stop Smoking Services service and monitoring guidance, which was issued in October 2007 and complements the NICE guidance, is "very important".

"The NICE guidance replaces previous national guidelines in the way you treat smokers,' he says. 'It does not change a lot of what NHS services were doing. It probably has some effects in very specific areas. For example, with respect to varenicline, some PCTs have been limiting its availability, but the guidance says it is an equal first-line choice."

One of the main priorities for implementation states that clinicians should offer nicotine replacement therapy, varenicline or bupropion, as appropriate, to those planning to stop smoking, without favouring one medication over another. However, only nicotine replacement therapy should be offered to those aged below 18 years and pregnant or breastfeeding women.

Service commissioners and PCTs must ensure that links exist between contraceptive services, fertility clinics and ante and postnatal services, to allow health professionals to advise on smoking cessation at various stages of a woman's life.

Dr Aveyard says the NICE guidance sets a framework: "In some ways it does not answer the question of what should be the balance between generalist and specialist provision and what scale of payments is best, although some might argue that this is fine, as it will allow people to work out what is best for their area."

These issues remain challenges for managers, he concludes.

NICE GUIDANCE: PRIORITIES

  • Ensure NHS stop smoking services target minority ethnic and socio-economically disadvantaged communities.

  • Aim to treat at least 5 per cent of those smoking/using tobacco, with a success rate of at least 35 per cent at four weeks, validated by CO monitoring.

  • Offer behavioural counselling, group therapy, pharmacotherapy (nicotine replacement therapy, varenicline or bupropion, as appropriate) or a combination of treatments.

  • Target women who smoke and are pregnant or are planning a pregnancy, and their partners and family members who smoke.