The recommendations in this section are presented without any reference to evidence statements. Appendix C in the original guideline document links the recommendations to specific evidence statements.
Smoking Cessation Services
Recommendation 1
Who is the target population?
Everyone who smokes or uses any other form of tobacco.
Who should take action?
- Primary care trusts (PCTs), strategic health authorities (SHAs).
- Commissioners of publicly funded smoking cessation services.
What action should they take?
- Determine the characteristics of the local population of people who smoke or use other forms of tobacco. Determine the prevalence of all forms of tobacco use locally.
- Ensure National Health Service (NHS) Stop Smoking Services target minority ethnic and socioeconomically disadvantaged communities in the local population.
- Ensure NHS Stop Smoking Services provide a good service by maintaining adequate staffing levels, including a full-time coordinator (or the equivalent).
- Set realistic performance targets for both the number of people using the service and the proportion who successfully quit smoking. These targets should reflect the demographics of the local population. Services should:
- Aim to treat at least 5% of the estimated local population of people who smoke or use tobacco in any form each year
- Aim for a success rate of at least 35% at 4 weeks, validated by carbon monoxide monitoring. This figure should be based on all those who start treatment, with success defined as not having smoked in the third and fourth week after the quit date. Success should be validated by a carbon monoxide (CO) monitor reading of less than 10 ppm at the 4-week point. This does not imply that treatment should stop at 4 weeks
- Audit performance data routinely and independently and make the results publicly available. Audits should also be carried out on exceptional results – 4-week quit rates lower than 35% or above 70% – to determine the reasons for unusual performance, and to help identify best practice and ensure it is being followed.
- Establish links between contraceptive services, fertility clinics and ante- and postnatal services. These links should ensure health professionals use the many opportunities available to them (at various stages of the woman's life) to offer smoking advice or referral to a specialist service, where appropriate. (See also NICE public health guidance 1 on smoking cessation in primary care and other settings at: www.nice.org.uk/PHI001)
Recommendation 2
Who is the target population?
Everyone who smokes or uses tobacco in any other form.
Who should take action?
Managers and providers of NHS Stop Smoking Services.
What action should they take?
- Offer behavioural counselling, group therapy, pharmacotherapy or a combination of treatments that have been proven to be effective (see the list at the start of section 4 of the original guideline document).
- Ensure clients receive behavioural support from a person who has had training and supervision that complies with the 'Standard for training in smoking cessation treatments' or its updates (www.nice.org.uk/page.aspx?o=502591).
- Provide tailored advice, counselling and support, particularly to clients from minority ethnic and disadvantaged groups. Provide services in the language chosen by clients, wherever possible.
- Ensure the local NHS Stop Smoking Service aims to treat minority ethnic and disadvantaged groups at least in proportion to their representation in the local population of tobacco users. (See also NICE public health guidance 1 on smoking cessation at: www.nice.org.uk/PHI001).
Recommendation 3
Who is the target population?
People who want to stop smoking.
Who should take action?
Commissioners and managers of telephone quitline services.
What action should they take?
- Ensure publicly sponsored telephone quitlines offer a rapid, positive and authoritative response. Where possible, callers whose first language is not English should have access to information and support in their chosen language.
- All staff should receive smoking cessation training (at least in brief interventions to help people stop smoking).
- Staff who offer counselling should be trained to at least level two (individual behavioural counselling) and preferably, they should hold an appropriate counselling qualification. Training should comply with the 'Standard for training in smoking cessation treatments' or its updates (www.nice.org.uk/page.aspx?o=502591).
Pharmacotherapies and Other Treatments
Recommendation 4
Who is the target population?
People who want to stop smoking.
Who should take action?
Healthcare professionals who advise on, or prescribe, nicotine replacement therapy (NRT), varenicline or bupropion.
What action should they take?
- Offer NRT, varenicline or bupropion, as appropriate, to people who are planning to stop smoking.
- Offer advice, encouragement and support, including referral to the NHS Stop Smoking Service, to help people in their attempt to quit.
- NRT, varenicline or bupropion should normally be prescribed as part of an abstinent-contingent treatment, in which the smoker makes a commitment to stop smoking on or before a particular date (target stop date). The prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date. Normally, this will be after 2 weeks of NRT therapy, and 3 to 4 weeks for varenicline and bupropion, to allow for the different methods of administration and mode of action. Subsequent prescriptions should be given only to people who have demonstrated, on re-assessment that their quit attempt is continuing.
- Explain the risks and benefits of using NRT to young people aged from 12 to 17, pregnant or breastfeeding women, and people who have unstable cardiovascular disorders. To maximise the benefits of NRT, people in these groups should also be strongly encouraged to use behavioural support in their quit attempt.
- Neither varenicline or bupropion should be offered to young people under 18 nor to pregnant or breastfeeding women.
- Varenicline or bupropion may be offered to people with unstable cardiovascular disorders, subject to clinical judgement
- If a smoker's attempt to quit is unsuccessful using NRT, varenicline or bupropion, do not offer a repeat prescription within 6 months unless special circumstances have hampered the person's initial attempt to stop smoking, when it may be reasonable to try again sooner.
- Do not offer NRT, varenicline or bupropion in any combination.
- Consider offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past.
- Do not favour one medication over another. The clinician and patient should choose the one that seems most likely to succeed.
- When deciding which therapies to use and in which order, discuss the options with the client and take into account:
- Whether a first offer of referral to the NHS Stop Smoking Service has been made
- Contra-indications and the potential for adverse effects
- The client's personal preferences
- The availability of appropriate counselling or support
- The likelihood that the client will follow the course of treatment
- Their previous experience of smoking cessation aids
This supersedes NICE technology appraisal guidance 39 on NRT and bupropion. (See also NICE technology appraisal guidance 123 on varenicline at www.nice.org.uk/TA123).
Recommendation 5
Who is the target population?
People who want to stop smoking, but not immediately.
Who should take action?
Healthcare professionals who advise on, or prescribe, NRT.
What action should they take?
Practitioners should provide NRT and appropriate support to individuals who want to follow the nicotine assisted reduction to stop (NARS) strategy only if it is part of a properly designed and conducted research study. Participants should include those who have repeatedly tried – and failed – to quit and those who are adamant that they do not want to quit abruptly.
Specific Groups
Recommendation 6
Who is the target population?
People receiving care and advice from a health professional in primary care or in hospital.
Who should take action?
- PCTs and acute trusts
- Healthcare professionals
What action should they take?
- Healthcare professionals should be trained to give brief advice on stopping tobacco use and should have contact with the local NHS Stop Smoking Service to which they can refer people.
- Healthcare professionals should identify and record the smoking and/or tobacco use status of all their patients. Those who use tobacco should be:
- Reminded at every suitable opportunity of the health benefits of stopping
- Offered brief advice and, if they want to stop using tobacco, referred to the local NHS Stop Smoking Service. If patients do not wish to attend the service, they should be offered brief advice and support to help them quit, and pharmacotherapy as appropriate
- Patients referred for elective surgery should be encouraged to stop smoking before the operation. Patients who want to stop smoking for good should also be referred to the local NHS Stop Smoking Service.
- Hospital patients who use tobacco in any form should be offered advice and, if appropriate, NRT from a trained health professional or smoking cessation adviser while in hospital to help them to quit. They should also be offered an appointment with their local NHS Stop Smoking Service. If they accept the offer, the appointment should be booked prior to their discharge. In exceptional circumstances it might be inappropriate to advise a patient to quit; for example, because of their presenting condition or personal situation.
- PCTs should ensure that NHS Stop Smoking Services can provide cessation support to hospitals. This should include a fast-track referral system after discharge for patients who have tried to quit smoking in hospital. PCTs should develop a clear referral plan with links between primary and acute trusts.
(See also NICE public health guidance 1 on smoking cessation at: www.nice.org.uk/PHI001).
Recommendation 7
Who is the target population?
People with cardiovascular or respiratory disease who smoke.
Who should take action?
- Healthcare professionals or counsellors who advise on, prescribe or dispense pharmacotherapies for stopping smoking
- Cardiac rehabilitation teams
What action should they take?
Offer brief advice or, preferably, behavioural support from the local NHS Stop Smoking Service and prescriptions of NRT, varenicline or bupropion, according to clinical judgement.
This supersedes NICE technology appraisal guidance 39 on NRT and bupropion. (See also NICE technology appraisal guidance 123 on varenicline at www.nice.org.uk/TA123 and NICE clinical guideline 12 on chronic obstructive pulmonary disease at www.nice.org.uk/CG012).
Recommendation 8
Who is the target population?
Women who smoke and who are either pregnant or are planning a pregnancy, and their partners and family members who smoke.
Who should take action?
All those responsible for providing health and support services for pregnant women, for those wishing to become pregnant, and for their partners. This includes: those working in fertility clinics, midwives, general practitioners (GPs), dentists, hospital and community pharmacists, and those working in children's centres, voluntary organisations and occupational health services.
What action should they take?
- At the first contact with the woman, discuss her smoking status, provide information about the risks of smoking to the unborn child and the hazards of exposure to secondhand smoke. Address any concerns she and her partner or family may have about stopping smoking.
- Offer personalised information, advice and support on how to stop smoking. Encourage pregnant women to use local NHS Stop Smoking Services and the NHS Pregnancy Smoking Helpline by providing details on when, where and how to access them. Consider visiting pregnant women at home if it is difficult for them to attend specialist services.
- Monitor smoking status and offer smoking cessation advice, encouragement and support throughout the pregnancy and beyond.
- Discuss the risks and benefits of NRT with pregnant women who smoke, particularly those who do not wish to accept the offer of help from the NHS Stop Smoking Service. If a woman expresses a clear wish to receive NRT, use professional judgement when deciding whether to offer a prescription.
- Advise pregnant women using nicotine patches to remove them before going to bed.
This supersedes NICE technology appraisal guidance 39 on NRT and bupropion. (See also NICE public health guidance 1 on smoking cessation at: http://www.nice.org.uk/PHI001).
Recommendation 9
Who is the target population?
Mothers of infants and young children, particularly breastfeeding mothers who smoke, and partners and family members who smoke.
Who should take action?
GPs, midwives, health visitors, community pharmacists and smoking cessation counsellors who advise on, or prescribe, NRT.
What action should they take?
- At the first contact, discuss the smoking status of the woman and her partner, provide information about the risks of secondhand smoke to young children and address any concerns about stopping smoking.
- Offer information, advice and support on how to quit smoking and encourage use of local NHS Stop Smoking Services by providing details on when, where and how to access them.
- Use any opportunity to offer those mothers who are (or who may be) eligible for the Healthy Start scheme practical and personalised information, advice and support to help them stop smoking.
- Discuss the risks and benefits of NRT with breastfeeding mothers who have tried but have been unable to stop smoking unaided. Use professional judgement to decide whether or not to advise use of NRT or to offer an NRT prescription.
- Advise breastfeeding women using nicotine patches to remove them before going to bed.
This supersedes NICE technology appraisal guidance 39 on NRT and bupropion. (See also NICE public health guidance 1 on smoking cessation at: http://www.nice.org.uk/PHI001).
Recommendation 10
Who is the target population?
Young people aged 12 to 17 who show a strong commitment to quit smoking.
Who should take action?
Healthcare professionals or counsellors who advise on, or prescribe, NRT.
What action should they take?
- Offer young people aged 12 to 17 information, advice and support on how to stop smoking. Encourage use of local NHS Stop Smoking Services by providing details on when, where and how to access them.
- Use professional judgement to decide whether or not to offer NRT to young people over 12 years who show clear evidence of nicotine dependence. If NRT is prescribed, offer it as part of a supervised regime.
This supersedes NICE technology appraisal guidance 39 on NRT and bupropion. (See also NICE public health guidance 1 on smoking cessation at: www.nice.org.uk/PHI001; NICE technology appraisal guidance 123 on varenicline at www.nice.org.uk/TA123).
Education and Training
Recommendation 11
Who is the target population?
NHS Stop Smoking Services advisers and coordinators.
Who should take action?
Commissioners and managers of NHS Stop Smoking Services.
What action should they take?
- Ensure training and continuing professional development is available for all those involved in providing stop smoking advice and support.
- Ensure training complies with the 'Standard for training in smoking cessation treatments' or its updates (www.nice.org.uk/page.aspx?o=502591).
Recommendation 12
Who is the target population?
Doctors, nurses, midwives, pharmacists, dentists, telephone quitline counsellors and others who advise people on how to quit smoking.
Who should take action?
Those responsible for the education and training of healthcare workers and others who advise people how to quit smoking.
What action should they take?
- Train all frontline healthcare staff to offer brief advice on smoking cessation in accordance with NICE guidance ('Brief interventions and referral for smoking cessation in primary care and other settings' www.nice.org.uk/PHI001). Also train them to make referrals, where necessary and possible, to NHS Stop Smoking Services and other publicly funded smoking cessation services.
- Ensure training on how to support people to quit smoking is part of the core curriculum for healthcare undergraduates and postgraduates.
- Train all NHS Stop Smoking Services practitioners using a programme that complies with the 'Standard for training in smoking cessation treatments' or its updates (www.nice.org.uk/page.aspx?o=502591).
- Provide additional, specialised training for those working with specific groups, for example, people with mental health problems, those who are hospitalised and pregnant women who smoke.
- Encourage and train healthcare professionals to ask patients or clients about all forms of tobacco use and to advise them of the dangers of exposure to secondhand smoke.
Strategies, Policies and Plans
Recommendation 13
Who is the target population?
Everyone who smokes or uses tobacco in any other form.
Who should take action?
PCTs, SHAs, local authorities, local strategic partnerships.
What action should they take?
- Set local targets for reducing tobacco use based on the characteristics of the local population and the prevalence of smoking and other forms of tobacco consumption, such as oral tobacco. Embed these targets in any partnership arrangements between local authorities and PCTs (for example, local area agreements).
- Develop a policy to ensure that effective smoking cessation services are provided as part of the local tobacco control strategy.
Recommendation 14
Who is the target population?
Everyone who smokes or uses tobacco in any other form.
Who should take action?
Organisers and planners of local, regional and national public education and communications campaigns.
What action should they take?
- Coordinate communications strategies to support the delivery of smoking cessation services, telephone quitlines, school-based interventions, forthcoming tobacco control policy changes and any other activities designed to help people to stop using tobacco.
- Develop and deliver communications strategies in partnership with the NHS, regional and local government and non-governmental organisations.
The strategies should:
- Use the best available evidence of effectiveness, such as reviews by the Cochrane Collaboration and the Global Dialogue for Effective Stop Smoking Campaigns (www.stopsmokingcampaigns.org)
- Be developed and evaluated using audience research
- Use 'why to' and 'how to' quit messages that are nonjudgemental, empathetic and respectful. For example, testimonials from people who smoke or used to smoke can work well
- Involve community pharmacies in local campaigns and maintain links with other professional groups such as dentists, fire services and voluntary groups
- Ensure campaigns are sufficiently extensive and sustained to have a reasonable chance of success
- Consider targeting and tailoring campaigns towards low income and minority ethnic groups to address inequalities
Recommendation 15
Who is the target population?
People who live or work in prisons, military establishments and care institutions, and who smoke or use tobacco in other forms.
Who should take action?
Managers of prisons, military establishments and long-stay health centres, such as mental healthcare units.
What action should they take?
Develop a policy, using guidance provided by the Department of Health, to ensure that effective smoking cessation services are provided and promoted.
(Go to www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Tobacco/index.htm)
(See also NICE public health guidance 1 on smoking cessation at: www.nice.org.uk/PHI001 and NICE public health guidance 5 on workplace smoking cessation at: www.nice.org.uk/PHI005)
Recommendation 16
Who is the target population?
Employees whose workplace is subject to regulations under the 2006 Health Act.
Who should take action?
Employers
What action should they take?
Negotiate a smokefree workplace policy with employees or their representatives. This should:
- State whether or not smoking breaks may be taken during working hours and, if so, where, how often and for how long
- Direct people who wish to stop smoking to services that offer appropriate support, for example, the NHS Stop Smoking Services
- Implement the NICE public health guidance, 'Workplace interventions to promote smoking cessation' (www.nice.org.uk/PHI005).
