Guidance

Screening and brief advice for alcohol and tobacco use in inpatient settings

Updated 19 December 2019

1. Introduction

The Preventing ill health by risky behaviours (2017 to 2019) and Alcohol and tobacco screening and brief advice (2019 to 2020) commissioning for quality and innovation (CQUIN) schemes aimed to embed screening for alcohol and tobacco use and to provide brief advice as part of routine inpatient care.

Providers of NHS-funded services in England should routinely:

• identify smokers and give brief advice, including an offer of nicotine replacement therapy (NRT) and referral to stop smoking support
• identify patients drinking above low risk levels and give brief advice or offer a referral for further assessment and specialist support (if the patient is possibly alcohol dependent)

This guidance supports providers of NHS services to carry out screening and implement brief interventions for alcohol and tobacco use. Providing these brief interventions will help deliver interventions described in the NHS Long Term Plan, which includes:

• offering NHS-funded tobacco treatment to all inpatients (including mental health), pregnant women and priority outpatient groups
• putting in place optimal alcohol care teams in hospitals with the highest rates of alcohol dependence-related admissions

2. Why you should screen and give brief advice for alcohol and tobacco use

Smoking and harmful alcohol use are among the most significant risk factors in England according to the global burden of disease study.

Smoking and harmful alcohol use costs the NHS an estimated £2 billion and £3.5 billion a year respectively. Smoking causes almost 80,000 premature deaths a year and contributes to 1.7 million hospital admissions. Harmful alcohol use is responsible for an estimated 24,000 premature deaths a year and contributes to more than 1 million hospital admissions.

The costs to society are significantly higher. Evidence suggests that smoking and harmful alcohol use cost around £12.6 billion and £21 billion each year respectively.

Preventing ill health by quitting smoking and drinking less alcohol can reduce:

• the burden on the NHS
• premature mortality and morbidity
• health inequalities

Modelling of the tobacco component of the 2017 to 2019 CQUIN by Public Health England suggests that it could reduce costs through fewer admissions and improved health of smokers and passive smokers; resulting in savings of £13 for each patient referred to stop smoking support and prescribed NRT each year over 4 years. This is a conservative estimate accounting for the reduced cost of hospital admissions only.

Findings from modelling by the University of Sheffield suggest that savings to the NHS (hospital admissions) resulting from IBA would amount to around £28 for each patient. In this scenario, the 960,000-people receiving IBA would save £110 million over 5 years, or £22 million a year. This amounts to a benefit to cost ratio of 5 to 1 in the first year.

Health Matters contains important facts, numbers and evidence of effective interventions, as well as case studies from a mental health provider and an acute provider that have implemented the CQUIN.

Implementing brief interventions for alcohol and tobacco use will make sure you put in place National Institute for Health and Care Excellence (NICE) guidance on reducing smoking in acute and mental health settings [PH48] and preventing alcohol use disorders [PH24].

3. What NHS trusts and other providers need to do: the interventions

Screening for alcohol and tobacco use and giving brief advice are non-specialist interventions which have sound evidence of effectiveness in reducing ill health and thereby the burden on health services, when delivered at scale.

The interventions are brief, and include components such as short screening questions, brief advice on the benefits of drinking less or how best to stop smoking, and where appropriate referral to specialist services. For example, a single intervention (including screening) should be between 30 seconds and 2 minutes depending on the complexity or interest of the patient.

3.1 Very brief advice for smoking cessation: ask, advise, act

Very brief advice for smoking cessation (VBA) aims to identify and support patients who smoke to make a quit attempt.

Healthcare professionals can provide VBA in as little as 30 seconds. The intervention is made up of 3 main parts: ask, advise and act.

Healthcare professionals do not need to know a lot about tobacco dependency to deliver VBA effectively. In its simplest form, they would:

1. Ask – and record smoking status. Is the patient a smoker, ex-smoker or a non-smoker?
2. Advise – on the best way of quitting. The best way of stopping smoking is with a combination of medication and specialist support.
3. Act – by offering a referral to specialist support and prescribing medication if appropriate. Smokers who get expert support are 3 times as likely to quit successfully.

A Cochrane review shows that smoking cessation interventions are effective for hospitalised patients regardless of the reason for their admission.

The quit rates among patients who want to quit and take up a referral to stop smoking services are between 15% and 20%, compared to 3% to 4% among those without a referral.

The Ottawa model has shown just how effective smoking cessation advice can be when offered to every person admitted to hospital regardless of what they are in for.

A study comparing patients who received the Ottawa model for smoking cessation intervention compared to usual care found that the smoking cessation intervention group were:

• more likely to give up smoking after 6 months (35% as opposed to 20% more likely)
• less likely to be readmitted to hospital for any cause after 30 days (50% less likely)
• less likely to visit accident and emergency (A&E) after 30 days (30% less likely)

In the longer term, participants in the Ottawa model group:

• were 21% less likely to be hospitalised after 2 years
• were 50% less likely to die by year 1
• had a 40% reduction in mortality after 2 years

3.2 Alcohol identification and brief advice

Alcohol identification and brief advice (IBA) aims to identify and influence patients who are drinking above the UK chief medical officers’ low risk guidelines.

IBA has the most impact when it helps identify and advise patients who are not dependent on alcohol, but whose drinking is increasing their risk of a wide range of health problems. The intervention may also identify dependent drinkers who need further specialist support.

Cochrane Library research suggests that IBA can reduce weekly drinking by 12% on average. Reducing regular consumption by any amount reduces the risk of ill health.

Healthcare professionals can arrange the intervention as a short informal conversation, for example, while undertaking routine care or as part of assessment or discharge.

Healthcare professionals do not need to know a lot about alcohol harm to deliver IBA well. In its simplest form, healthcare staff would:

1. Ask patients the 3 AUDIT C questions and score their answers, or give patients an AUDIT C scratch card to complete.
2. Tell the patient what their score says about their health risk.
3. Provide an information leaflet to patients who drink above low risk levels (but are not dependent) about the harms and benefits of cutting down their drinking.

Healthcare professionals who identify patients as potentially dependent drinkers should refer them for a specialist alcohol assessment.

Patients identified as harmful or potentially dependent drinkers should be considered for further investigation of liver disease in line with NICE guideline [NG50].

4. Brief advice e-learning course

Health Education England provides a free e-learning course that covers very brief advice on smoking and alcohol identification and brief advice.

5. More comprehensive e-learning on alcohol and smoking

Health Education England also provides a range of comprehensive e-learning courses on alcohol identification and brief advice which may be of interest. The courses include evidence from more than 60 controlled trials over 30 years.

There are courses for different settings, including:

• hospitals
• primary care
• community pharmacy
• dental teams

The National Centre for Smoking Cessation and Training provides e-learning courses for delivering very brief advice on stopping smoking. There is also a range of resources focused on supporting stopping smoking in secondary care, mental health and pregnancy services.

6. Other useful tools and resources

NHS Smokefree offers a telephone helpline on 0300 123 1044 and you can find your local stop smoking service on their website.

Patients can contact the national alcohol helpline Drinkline on 0300 123 1110 and there is an alcohol service directory on the NHS website.

The 5 alcohol-use screening tests, known as the alcohol use disorders identification test (AUDIT) tools, help healthcare professionals to assess a patient’s level of risk to alcohol harm.

Healthcare providers can use the briefing template to tell their staff about carrying out alcohol and tobacco screenings and giving brief advice.

Trainers can use video clips from the Health Education England e-learning course in face-to-face sessions to show examples of staff delivering both IBA and VBA.

The Knowledge Hub provides a forum for healthcare staff implementing the CQUIN. It is a place to share experiences, ask questions of others and give advice. The Knowledge Hub also provides a library where staff can share resources.

The One You alcohol unit wheel is an interactive tool to help patients calculate the number of units and calories in the alcoholic drinks they consume.