Modifiable risk factors: high impact interventions

  1. Tobacco dependence identification and treatment in secondary care
  2. Weight management services for people with diabetes and/or hypertension
  3. Alcohol care teams

Download these high impact interventions as a table (PDF).

Tobacco dependence identification and treatment in secondary care

Identification of smokers in inpatient hospital settings and maternity services, providing advice and treatment (behavioural and/or pharmacological).

Support to stop smoking in secondary care services: inpatient and maternal services.

Cost of intervention/return on investment

The CURE programme estimates a cost per quit at £475 (an est. cost per patient is closer to £120)  The CURE programme estimates a ROI of £2.12 (of which £1.06 is cashable) with a payback period of 4 years.

The Royal College of Physicians (RCP) estimated that adopting the Ottawa Model of Smoking Cessation in the NHS, the net return would be £60m in the first year with an additional c£206m through supporting NHS staff to quit (by reducing absenteeism, ill-health treatment and loss of productivity).

Long Term Plan (LTP) modelling estimated that in the first full year (100% rollout) for inpatient and maternity services, the combined cost benefit ratio would be £1.85 to the NHS.

The National Institute for Health and Care Excellence (NICE) reports that a combination of varenicline and behavioural support provides a £1.65 return for every £1 spent through the avoidance of treatment costs for five key long-term conditions including stroke.

Impact on demand

LTP modelling estimated nearly 42,000 admissions and c150,000 bed days saved in first full year of operation (100% rollout).

Smokers are 36% more likely to be admitted to hospital (3,000 smokers per day being admitted) and 35% more likely to see their GP compared to non-smokers.

The Ottawa Model of Smoking Cessation model (system-wide model) demonstrated a reduction in the relative risk of readmission and A&E attendance by 6% and 3% respectively at 1 year with a reduction in smoking-related physician visits (specialist 5% and GP 2%).

Expected outcomes

LTP modelling Office for Health Improvement and Disparities (OHID) estimated 167,000 people (inpatient and maternity services) undertaking a quit attempt with an estimated 57,000 quits and 1,611 lives saved (first full year of operation at 100% rollout).

Benefits of quitting smoking are realised in the short and long term:



Weight management services for people with diabetes and/or hypertension eg the NHS Digital Weight Management Programme

Identification by GP practices and community pharmacists and referral to structured service to support people to lose weight and reduce their associated clinical risk.

Rising population rates of obesity translate to increasing costs, in 2014/15 the NHS spent £6.1 billion on treating obesity-related ill health, this is forecast to rise to £9.7 billion per year by 2050.

Evidence from systematic reviews and large randomised controlled trials on benefits of weight loss to diabetes and hypertension (as well as wider CVD risk factors).

Cost of intervention/return on investment

The NHS Digital Weight Management Programme is centrally funded by NHS England. Referrals can be made locally by GPs or community pharmacists – these are currently nationally incentivised through the GP Enhanced Service or the Pharmacy Quality Scheme.

The Digital Weight Management Programme is a digital offer, supporting reach into communities who do not traditionally access face to-face weight management services.  Average weight change in those who complete the 12-week programme is estimated between 3-4kg lost.

Initial cost effectiveness models are calculating the Digital Weight Management Programme as highly cost effective.

Impact on demand

Obesity was a factor in over one million admissions in England in 19/20; this was over twice as likely in the most compared to the least deprived areas. There were approximately 11,000 hospital admissions with a primary diagnosis of obesity.

The Covid pandemic highlighted the higher risk posed to those living with obesity. Nearly 8% of critically ill patients with COVID-19 in intensive care units have been morbidly obese, compared with 2.9% of the general population.

Expected outcomes

Weight management services in people with diabetes and/or hypertension have been demonstrated to lead to improvements in blood pressure, blood glucose, HbA1C and triglycerides.

A Cochrane review on the long-term effects of weight-reducing diets in people with hypertension found that a reduction in body weight of approximately 4 kg would achieve a reduction of approximately 4.5 mmHg systolic blood pressure and of approximately 3.2 mmHg diastolic blood pressure.



Alcohol care teams

Alcohol-related liver disease is the one of the leading causes of death in the UK and is on the rise, having increased 43% over the last two decades and by an unprecedented 21% in 2020.

In 2020, 5,608 alcohol-related liver deaths were recorded in England, a rise of almost 21% compared to 2019. This is substantially above pre-COVID trends – between 2018 and 2019 the increase was under 3%.

Approximately 1 in 10 adults admitted to acute hospital may be alcohol dependent. Alcohol disorders places a disproportionate burden on hospital services; alcohol care teams (ACTs) help to address this.

Cost of intervention/return on investment

A National Institute for Health and Care Excellence (NICE) quality improvement case study on the impact of an alcohol care team in Bolton, found it saved 2,000 alcohol related bed days in its first year and reduced readmissions by 3%.

A calculated return on investment of £3.85 for every £1 invested was derived from the Bolton case study.

Impact on demand

NHS England modelling suggest benefit of around 75,000 bed days per year based on 25% roll out of ACTs – circa 1.5k per hospital site.

A recent NHS – commissioned report estimates that over the next 20 years, there will be an additional 207,597 alcohol-attributable hospital admissions and 7,153 alcohol-attributable deaths, costing the NHS an additional £1.1bn compared to 2019 alcohol consumption levels.

Expected outcomes

The risk of alcohol-related mortality increases steadily after 112g (approximately 14 units) average weekly consumption and is more accelerated with heavy drinking. As a consequence, reduction of drinking, and especially of heavy and dependent drinking – a key role for ACTs – is the main mechanism to reduce alcohol-related mortality.

High quality systematic review suggests approximately 1 in 10 adults admitted to acute hospital may be alcohol dependent.