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Smoking cessation in secondary care

About

What is covered

This pathway covers smoking cessation in secondary care, including acute, maternity and mental health services.
Secondary care providers have a duty of care to protect the health of, and promote healthy behaviour among, people who use or work in their services. This duty of care includes providing them with effective support to stop smoking or to abstain from smoking while using or working in secondary care services.

Updates

Updates to this pathway

6 August 2015 Smoking cessation: supporting people to stop smoking (NICE quality standard 43) added to this pathway.
24 March 2015 Smoking: reducing tobacco use (NICE quality standard 82) added to this pathway.
18 September 2014 2014 Minor maintenance updates.
3 September 2014 2014 Minor maintenance updates.
27 January 2014 Minor maintenance updates.

Your responsibility

Guidelines

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this pathway is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the pathway to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Technology appraisals

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this pathway is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the pathway does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Smoking cessation in secondary care: acute, maternity and mental health services

What is covered

This pathway covers smoking cessation in secondary care, including acute, maternity and mental health services.
Secondary care providers have a duty of care to protect the health of, and promote healthy behaviour among, people who use or work in their services. This duty of care includes providing them with effective support to stop smoking or to abstain from smoking while using or working in secondary care services.

Updates

Updates to this pathway

6 August 2015 Smoking cessation: supporting people to stop smoking (NICE quality standard 43) added to this pathway.
24 March 2015 Smoking: reducing tobacco use (NICE quality standard 82) added to this pathway.
18 September 2014 2014 Minor maintenance updates.
3 September 2014 2014 Minor maintenance updates.
27 January 2014 Minor maintenance updates.

Sources

NICE guidance and other sources used to create this pathway.
Varenicline for smoking cessation (2007) NICE technology appraisal guidance 123

Quality standards

Smoking cessation quality standard

These quality statements are taken from the smoking cessation: supporting people to stop smoking quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statements

Identifying people who smoke

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People are asked if they smoke by their healthcare practitioner, and those who smoke are offered advice on how to stop.

Rationale

There is evidence that people who smoke are receptive to smoking cessation advice in all healthcare settings. It is therefore important that healthcare practitioners proactively ask people if they smoke, and offer advice on how to stop.

Quality measures

Structure
Evidence of local arrangements to ensure that people are asked if they smoke by their healthcare practitioner, and those who smoke are offered advice on how to stop.
Data source: Local data collection.
Process
a) Proportion of people who are asked if they smoke by their healthcare practitioner.
Numerator – the number of people in the denominator who are asked if they smoke by their healthcare practitioner.
Denominator – the number of people who have face-to-face contact with a healthcare practitioner.
Data source: a) Local data collection. The quality and outcomes framework (QOF) contains indicators related to identifying and supporting people who smoke in primary care.
b) Proportion of people who smoke who receive advice on how to stop.
Numerator – the number of people in the denominator who receive advice on how to stop.
Denominator – the number of people who report that they smoke during face-to-face contact with a healthcare practitioner.
Data source: b) Local data collection. NICE public health guidance 10: audit support – criterion 3i. The QOF contains indicators related to identifying and supporting people who smoke in primary care.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people to be asked if they smoke by their healthcare practitioner, and for those who smoke to be offered advice on how to stop.
Healthcare practitioners ask their patients if they smoke, and offer those who smoke advice on how to stop.
Commissioners ensure that they commission services where healthcare practitioners ask their patients if they smoke, and that they offer those who smoke advice on how to stop.

What the quality statement means for patients, service users and carers

People are asked if they smoke by their healthcare practitioners, and those who smoke are offered advice on how to stop.

Source guidance

Definition of terms used in this quality statement

Healthcare practitioners include, but are not limited to, doctors, nurses, midwives, pharmacists, dentists, opticians and allied health professionals.
Advice can vary by healthcare setting. In the context of primary care settings, this would involve evidence-based, opportunistic advice offered to people who smoke about the options and support available to help them stop smoking. In the context of secondary care settings, advice may involve the practitioner providing people who smoke with information and referring them to an evidence-based smoking cessation service.
The National Centre for Smoking Cessation and Training offers a training module on the delivery of evidence-based smoking cessation interventions, to ensure that this is done in a sensitive way within the brief time available with the patient.
This statement is linked to statement 2, because advice on how to stop may include a referral to an evidence-based smoking cessation service.

Equality and diversity considerations

Advice should be culturally appropriate and accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.
Advice may include referral to an evidence-based smoking cessation service. NICE public health guidance 10 states that such services should target minority ethnic and socioeconomically disadvantaged communities in the local population; it is important to ensure that services are easily accessible by people from these groups and that they are encouraged to use them.
Lesbian, gay, bisexual and transgender (LGBT) groups have higher smoking prevalence rates than the general population, and as such, services should be accessible and commissioned to address this need.
Healthcare practitioners should be sensitive to the issue of smoking in young people. NICE guidance recommends that young people aged 12–17 who smoke should be offered information, advice and support on how to stop smoking and be encouraged to use local evidence-based smoking cessation services.
Practitioners should be aware that some pregnant women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.

Referral to smoking cessation services

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who smoke are offered a referral to an evidence-based smoking cessation service.

Rationale

Smoking cessation services provide the most effective route to stopping smoking, but many people who smoke do not use these services when they try to stop. It is therefore important that practitioners are aware of and make use of the opportunities to refer people who smoke to an evidence-based smoking cessation service.
Quality statement 5 in the NICE quality standard on antenatal care sets out the high-quality requirements for ensuring that pregnant women who smoke are referred to an evidence-based smoking cessation service.

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke are offered a referral to an evidence-based smoking cessation service.
Data source: Local data collection.
Process
Proportion of people who smoke who are referred to an evidence-based smoking cessation service.
Numerator – the number of people in the denominator who are referred to an evidence-based smoking cessation service.
Denominator – the number of people identified as smokers in any healthcare setting.
Data source: Local data collection. The quality and outcomes framework (QOF) contains indicators related to support in primary care for people who smoke.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people who smoke to be offered a referral to an evidence-based smoking cessation service.
Healthcare practitioners offer people who smoke a referral to an evidence-based smoking cessation service.
Commissioners ensure that they commission services that offer people who smoke a referral to an evidence-based smoking cessation service.

What the quality statement means for patients, service users and carers

People who smoke are offered a referral to an evidence-based smoking cessation service to help them stop smoking.

Source guidance

Definition of terms used in this quality statement

Healthcare practitioners include, but are not limited to, doctors, nurses, midwives, pharmacists, dentists, opticians and allied health professionals.
Evidence-based smoking cessation services are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. NICE public health guidance 10 describes key characteristics of an evidence-based smoking cessation service. These include addressing the needs of minority communities in the local population, maintaining adequate staffing levels and benchmarking and reporting service outcomes.
The National Centre for Smoking Cessation and Training offers training modules for people delivering smoking cessation interventions.
This statement is linked to statement 1, because advice on how to stop may include a referral to an evidence-based smoking cessation service.
Quality statement 5 in the NICE quality standard on antenatal care states that 'Pregnant women who smoke are referred to an evidence-based stop smoking service at the booking appointment' and the appropriate referral criteria are defined. The supporting information also states that the midwife may provide the pregnant woman with information (in a variety of formats, for example, a leaflet) about the risks to the unborn child of smoking when pregnant and the hazards of exposure to secondhand smoke for both mother and baby.

Equality and diversity considerations

NICE public health guidance 10 states that evidence-based smoking cessation services should target minority ethnic and socioeconomically disadvantaged communities in the local population; it is important to ensure that services are easily accessible by people from these groups and that they are encouraged to use them.
Lesbian, gay, bisexual and transgender (LGBT) groups have higher smoking prevalence rates than the general population, and as such, services should be accessible and commissioned to address this need.
Healthcare practitioners should be sensitive to the issue of smoking in young people. NICE guidance recommends that young people aged 12–17 who smoke should be offered information, advice and support on how to stop smoking and be encouraged to use evidence-based smoking cessation services.
Practitioners should be aware that some pregnant women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.

Behavioural support with pharmacotherapy

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who smoke are offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service.

Rationale

People who smoke are more likely to stop smoking if they are offered a combination of interventions, with combined behavioural support and pharmacotherapy the most likely to be successful.

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke are offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service.
Data source: Local data collection.
Process
Proportion of people who receive behavioural support with pharmacotherapy from an evidence-based smoking cessation service.
Numerator – the number of people in the denominator who receive behavioural support with pharmacotherapy from an evidence-based smoking cessation service.
Denominator – the number of people referred to an evidence-based smoking cessation service.
Data source: Local data collection. Contained in NICE public health guidance 10: audit support – criterion 7; Statistics on NHS Stop Smoking Services: England, April 2011 – March 2012 from the Health and Social Care Information Centre reports on smoking cessation interventions.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people who smoke to be offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service.
Healthcare practitioners offer behavioural support with pharmacotherapy to people who have been referred to an evidence-based smoking cessation service.
Commissioners ensure that they commission evidence-based smoking cessation services that offer people who smoke behavioural support with pharmacotherapy.

What the quality statement means for patients, service users and carers

People who have been referred to an evidence-based smoking cessation service are offered behavioural support (which may be either individual or group counselling) together with drug treatment.

Source guidance

Definition of terms used in this quality statement

Behavioural support
This can be individual behavioural therapy or group behaviour therapy.
NICE public health guidance 10 states that individual behavioural therapy involves scheduled face-to-face meetings between someone who smokes and a practitioner from the smoking cessation service trained in smoking cessation. Typically, it involves weekly sessions over a period of at least 4 weeks after the quit date and is normally combined with pharmacotherapy.
NICE public health guidance 10 states that group behaviour therapy involves scheduled meetings where people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy). This therapy is offered weekly for at least the first 4 weeks of a quit attempt (that is, for 4 weeks following the quit date). It is normally combined with pharmacotherapy.
Pharmacotherapy
Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion.
NICE public health guidance 10 states that neither varenicline nor bupropion should be offered to young people under 18. Professional judgement should be used 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. Varenicline or bupropion may be offered to people with unstable cardiovascular disorders who smoke, subject to clinical judgement.
NICE public health guidance 26 states that there should be a discussion about the risks and benefits of NRT with pregnant women who smoke. Nicotine replacement therapy should be offered if smoking cessation without NRT fails, or practitioner judgement should be used if women express a clear preference for NRT. Neither varenicline nor bupropion should be offered to pregnant or breastfeeding women.
A summary of further considerations relating to pharmacotherapy is provided in quality statement 4.
Evidence-based stop smoking services
These are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. NICE public health guidance 10 describes key characteristics of an evidence-based smoking cessation service. These include addressing the needs of minority communities in the local population, maintaining adequate staffing levels and benchmarking and reporting service outcomes.

Pharmacotherapy

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course.

Rationale

Pharmacotherapy interventions act as an aid to help people to stop smoking, and it is important that people who seek support to stop smoking receive the full course of their chosen pharmacotherapy to increase the chances of success.

Quality measures

Structure
Evidence of local arrangements to ensure that people who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course.
Data source: Local data collection.
Process
Proportion of people who seek support to stop smoking and who agree to take pharmacotherapy who receive a full course.
Numerator – the number of people in the denominator who receive a full course of pharmacotherapy.
Denominator – the number of people who seek support to stop smoking and who agree to take pharmacotherapy.
Data source: Local data collection. Contained in NICE public health guidance 1: audit – criterion 5 and NICE public health guidance 10: audit support – criteria 5–8; Statistics on NHS Stop Smoking Services: England, April 2011 – March 2012 from the Health and Social Care Information Centre reports on smoking cessation interventions.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place so that people who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course.
Healthcare practitioners offer a full course of pharmacotherapy to people who seek support to stop smoking and who agree to take pharmacotherapy.
Commissioners ensure that they commission services that offer a full course of pharmacotherapy to people who seek support to stop smoking and who agree to take pharmacotherapy.

What the quality statement means for patients, service users and carers

People who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course of drug treatment.

Source guidance

Definition of terms used in this quality statement

Pharmacotherapy
Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion.
NICE public health guidance 10 states that healthcare professionals who prescribe nicotine replacement therapy (NRT), varenicline or bupropion should offer advice, encouragement and support including referral to an evidence-based smoking cessation service. Pharmacotherapy 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. NICE technology appraisal guidance 123 states that varenicline should normally be prescribed only as part of a programme of behavioural support.
NICE public health guidance 10 states that neither varenicline nor bupropion should be offered to young people under 18. Professional judgement should be used 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. Varenicline or bupropion may be offered to people with unstable cardiovascular disorders who smoke, subject to clinical judgement.
NICE public health guidance 26 states that there should be a discussion about the risks and benefits of NRT with pregnant women who smoke. Nicotine replacement therapy should be offered if smoking cessation without NRT fails, or practitioner judgement should be used if women express a clear preference for NRT. Neither varenicline nor bupropion should be offered to pregnant or breastfeeding women.
It is important that people who smoke who receive pharmacotherapy receive a full course, which will vary depending on the individual smoker. A full course for NRT is at least 8 weeks, for varenicline it is at least 12 weeks and for bupropion it is at least 8 weeks. NICE public health guidance 10 outlines that the prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date with subsequent prescriptions given only to people who have demonstrated, on re-assessment, that their quit attempt is continuing.
Drugs with a metabolism that is affected by smoking (or stopping smoking) should be monitored, and the dosage adjusted if appropriate.

Equality and diversity considerations

There should be a discussion about risks and benefits of using NRT with young people aged 12–17 and pregnant or breastfeeding women.

Outcome measurement

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.

Rationale

Recording smoking status using carbon monoxide testing after 4 weeks provides an incentive for people who are attempting to stop, and is an objective way to measure individual and service level outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Data source: Local data collection.
Process
Proportion of people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Numerator – the number of people in the denominator who are assessed for carbon monoxide levels 4 weeks after the quit date.
Denominator – the number of people who smoke who have set a quit date with an evidence-based smoking cessation service.
Data source: Local data collection. The Health and Social Care Information Centre's Indicator Portal collects data on the number of people who smoke who successfully quit at the 4-week follow-up per 100,000 population.
Outcome
4-week quit rates.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place so that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Healthcare practitioners ensure that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Commissioners ensure that they commission services for people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.

What the quality statement means for patients, service users and carers

People who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.

Source guidance

Definition of terms used in this quality statement

NICE public health guidance 10 states that success should be validated by a carbon monoxide monitor reading of less than 10 ppm at the 4-week point. This does not imply that treatment should stop at 4 weeks.
Evidence-based smoking cessation services
These are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. NICE public health guidance 10 describes key characteristics of an evidence-based smoking cessation service. These include addressing the needs of minority communities in the local population, maintaining adequate staffing levels and benchmarking and reporting service outcomes.

Schools and colleges: interventions

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Schools and colleges deliver combined interventions to stop children and young people taking up smoking by improving their social competence and awareness of social influences.

Rationale

Schools and colleges have an important role in helping children and young people to understand the harm associated with tobacco products. Most schools and colleges have already implemented smokefree policies, and teaching about tobacco use and its impact is part of the curriculum. However, children and young people still face substantial pressures to start smoking from their peers, family members, the media and the tobacco industry. Combined interventions to improve social competence and to make students aware of the social influences that support smoking are effective in preventing children and young people from taking up smoking.

Quality measures

Structure
Evidence of arrangements within local schools and colleges to deliver combined interventions to stop children and young people taking up smoking by improving their social competence and awareness of social influences.
Data source: Local data collection.
Process
a) Proportion of schools and colleges that deliver combined interventions to stop children and young people taking up smoking by improving their social competence and awareness of social influences.
Numerator – the number in the denominator that deliver combined interventions to stop children and young people taking up smoking by improving their social competence and awareness of social influences.
Denominator – the number of schools and colleges in a specified geographic area.
Data source: Local data collection.
b) Proportion of children and young people who receive combined interventions to stop them taking up smoking by improving their social competence and awareness of social influences.
Numerator – the number in the denominator who receive combined interventions to stop them taking up smoking by improving their social competence and awareness of social influences.
Denominator – the number of children and young people in schools and colleges in a specified geographic area.
Data source: Local data collection.
Outcome
Proportion of children and young people who have tried smoking at least once.
Data source: Statistics on smoking, England 2014 covers the national prevalence of smoking among young people aged 16–19 and secondary school students (mostly aged 11–15).

What the quality statement means for schools and colleges

Schools and colleges deliver combined interventions to stop children and young people taking up smoking by improving their social competence and awareness of social influences.

What the quality statement means for children and young people

Children and young people take part in programmes at their school or college that help them to refuse offers of tobacco products by improving their self esteem, how they cope with stress, and general social and assertive skills.

Source guidance

Definitions of terms used in this quality statement

Schools and colleges
In this quality standard schools and colleges include:
  • maintained and independent primary, secondary and special schools
  • city technology colleges and academies
  • pupil referral units, secure training and local authority secure units
  • further education colleges
  • ‘extended schools’ where childcare or informal education is provided outside school hours. [NICE guideline PH23]
Social competence interventions
A group of interventions that aim to help children and young people refuse offers to smoke by improving their general social competence. Programmes benefit from including social learning processes or life skills such as:
  • problem solving and decision making
  • cognitive skills for resisting interpersonal or media influences
  • increased self control and self esteem
  • coping strategies for stress
  • general social and assertive skills.
These interventions can be peer led or adult led and can have tobacco products as a focus or be more general.
[Cochrane review and expert opinion]
Social influences interventions
Interventions that aim to increase awareness of social influences that promote tobacco use and help students overcome these influences. Programmes adopt resistance skills training in which students are taught how to:
  • deal with peer pressure
  • deal with high risk situations
  • effectively refuse direct and indirect attempts to persuade them to use tobacco products.
[Cochrane review and expert opinion]

Equality and diversity considerations

Smoking rates are higher among those excluded from school and they will not be able to benefit from these interventions. Other activities carried out locally should address the needs of this group.

Schools and colleges: smokefree grounds

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Schools and colleges do not allow smoking anywhere in their grounds and remove any areas previously designated for smoking.

Rationale

Most schools and colleges already have a smokefree policy in place, which includes having smokefree grounds. However, some of the smokefree grounds still allow smoking in designated smoking areas and may even provide smoking shelters. Allowing anyone to smoke anywhere in the school grounds at any time, makes it seem an acceptable activity. Providing outdoor smoking areas facilitates smoking.

Quality measures

Structure
Evidence of arrangements in local schools and colleges to operate smokefree grounds and remove any areas designated for smoking.
Data source: Local data collection.
Process
a) Proportion of schools and colleges that do not allow smoking anywhere in the grounds.
Numerator – The number in the denominator that do not allow smoking anywhere in the grounds.
Denominator – The number of schools and colleges in the specified geographic area.
Data source: Local data collection.
b) Proportion of schools and colleges with no designated areas for smoking.
Numerator – The number in the denominator with no designated areas for smoking.
Denominator – The number of schools and colleges in the specified geographic area.
Data source: Local data collection.
Outcome
Schools and colleges with smokefree grounds and no areas designated for smoking.
Data source: Local data collection.

What the quality statement means for schools and colleges

Schools and colleges ensure that smoking is not allowed anywhere in the grounds and that the smokefree policy applies to anyone using the premises for any purpose at any time. They should also remove any existing areas previously designated for smoking in the grounds.

What the quality statement means for children and young people

Children and young people attend schools and colleges that do not allow smoking anywhere in the school or the school grounds at any time. The schools and colleges do not have any areas in the grounds set aside for smoking.

Source guidance

Definitions of terms used in this quality statement

Schools and colleges
In this quality standard schools and colleges include:
  • maintained and independent primary, secondary and special schools
  • city technology colleges and academies
  • pupil referral units, secure training and local authority secure units
  • further education colleges
  • ‘extended schools’ where childcare or informal education is provided outside school hours. [NICE guideline PH23]

Equality and diversity considerations

Smoking rates are higher among those excluded from school and they will not be able to benefit from these actions. Other activities carried out locally should address the needs of this group.

Underage sales

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Trading standards identify and take action against retailers that sell tobacco products to people under 18.

Rationale

It is illegal to sell tobacco products to anyone under 18. Trading standards should work in partnership with retailers, police and the wider community to gather reliable information and take action against local retailers who sell tobacco to people under 18. This may include providing advice and guidance to the retailers, test purchasing and taking legal action.

Quality measures

Structure
a) Evidence of local arrangements to obtain and interpret information to identify retailers that sell tobacco products to people under 18.
Data source: Local data collection.
b) Evidence of local actions undertaken to prevent retailers from selling tobacco products to people under 18.
Data source: Local data collection.
Process
a) Proportion of tobacco test purchases with a recorded underage sale.
Numerator – The number in the denominator with a recorded underage sale.
Denominator – The number of tobacco test purchases carried out in a specified geographic area.
Data source: Tobacco Control Survey, England. Trading Standards Institute.
b) Proportion of retailers with a recorded underage sale followed up with advice to the retailer.
Numerator – The number in the denominator followed up with advice to the retailer.
Denominator – The number of test purchases with a recorded underage sale in a specified geographic area.
Data source: Tobacco Control Survey, England. Trading Standards Institute.
c) Proportion of individuals sanctioned for persistently selling tobacco to people under 18.
Numerator – The number in the denominator sanctioned for persistently selling tobacco to people under 18.
Denominator – The number of individuals identified as persistently selling tobacco to people under 18 in a specified geographic area.
Data source: Tobacco Control Survey, England. Trading Standards Institute.
d) Proportion of tobacco sales outlets sanctioned for persistently selling tobacco to people under 18.
Numerator – The number in the denominator sanctioned for persistently selling tobacco to people under 18.
Denominator – The number of tobacco sales outlets identified as persistently selling tobacco to people under 18 in a specified geographic area.
Data source: Tobacco Control Survey, England. Trading Standards Institute.
Outcome
Incidence of underage tobacco sales.
Data source: Local data collection.

What the quality statement means for local trading standards and local retailers

Local trading standards work in partnership with retailers, the police and the wider community to gather reliable information and take action against local retailers who sell tobacco to people under 18.
Local retailers are subject to test purchase operations and if underage tobacco sales are recorded, further action is taken. They work with local trading standards in order to comply with the legislation. If the retailers are found persistently selling tobacco products to people under 18, they can be sanctioned by magistrate’ courts.

What the quality statement means for children and young people

Children and young people find it hard to buy tobacco products and hard to start or carry on smoking. This means that they are better protected from smoking related harm.

Source guidance

Definitions of terms used in this quality statement

Identifying retailers
Local trading standards, the police, HM Revenue and Customs, voluntary and community groups work in partnership to obtain, interpret and act on reliable intelligence to identify retailers that sell tobacco products to people under 18.
Trading standards also work with local retailers to increase awareness of, and compliance with, the tobacco legislation. [NICE guideline PH14 and expert opinion]
Taking actions against retailers
Actions taken against retailers include:
  • undertaking test purchases to detect breaches in the law at retailers identified by local intelligence
  • raising awareness of tobacco legislation among retailers and providing advice to those retailers found selling tobacco to anyone under 18
  • using sanctions and taking legal action against retailers.
Trading standards can apply to the magistrates’ court to impose fines or sanctions on the retailers. The maximum fine is £2500. When a person is convicted of making an illegal sale to anyone under 18 and, on at least 2 other occasions within a 2 year period, has committed other similar offences (these do not need to have resulted in a conviction), a sanction may be applied for. The magistrates’ court can issue a Restricted Premises Order or a Restricted Sale Order, or both.
Restricted Premises Order – The retail premises is prohibited from selling tobacco products for a period of up to 12 months.
Restricted Sale Order – A named person is prohibited from selling tobacco or managing premises in relation to the sale of tobacco products for a period of up to 12 months – the business may still sell tobacco but the individual may not. [Responsible tobacco retailing, 2014 and expert opinion]

Equality and diversity considerations

Smoking is more common in socially deprived areas and children and young people from poorer socioeconomic backgrounds take up smoking at an earlier age. Targeting retailers with awareness raising campaigns can potentially have more impact in disadvantaged areas.

Workplace policy

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Employers allow employees to access evidence based ‘stop smoking’ support during working hours without loss of pay.

Rationale

Many employers already have a policy outlining support to help employees to quit smoking. However, in practice, employees find it difficult to get time off to access ‘stop smoking’ services when needed. NHS and local authority employers should set an example in implementing this quality statement.
Evidence shows that people who smoke take an average of 30 minutes in cigarette breaks within business hours each day. A typical ‘stop smoking’ intervention lasts 30 minutes, once a week for the first 4 weeks after the quit attempt, then less frequently for a further 8 weeks. By enabling employees to access ‘stop smoking’ services, employers are likely to realise substantial benefits, such as increased productivity, decreased sickness rates and improved adherence to smokefree policies. More details about the economic gains for the employers can be found using the tobacco return on investment tool.

Quality measures

Structure
Evidence of HR policies that allow employees to access ‘stop smoking’ support during working hours without loss of pay.
Data source: Local data collection.
Process
a) Proportion of employees who wanted to access ‘stop smoking’ support during working hours and did so.
Numerator – The number in the denominator who accessed ‘stop smoking’ support during working hours.
Denominator – The number of employees who wanted to access ‘stop smoking’ support during working hours.
Data source: Local data collection.
b) Proportion of employees who accessed ‘stop smoking’ support during working hours without loss of pay.
Numerator – The number in the denominator who did not lose pay.
Denominator – The number of employees who accessed ‘stop smoking’ support during working hours.
Data source: Local data collection.

What the quality statement means for commissioners

Commissioners of ‘stop smoking’ services ensure that there is capacity within the ‘stop smoking’ services to deliver support to employers who want to help their employees to stop smoking.

What the quality statement means for employers and employees

All employers encourage employees who smoke (including students, apprentices and volunteers) to access ‘stop smoking’ support. They facilitate employees to access ‘stop smoking’ services by allowing them to attend during working hours without loss of pay. Employers may choose to organise on site ‘stop smoking’ services if that is feasible.
Employees who smoke can attend ‘stop smoking’ services during working hours, without losing pay.

What the quality statement means for managers of ‘stop smoking’ services

‘Stop smoking’ services proactively engage with local businesses by offering their support and promoting their services. In particular, they target businesses with high numbers of staff working in routine and manual jobs. This may mean that ‘stop smoking’ services are provided on site and there is increased demand on the service.

Source guidance

Definitions of terms used in this quality statement

Support offered by ‘stop smoking’ services
Support offered by ‘stop smoking’ services includes but is not limited to:
  • behavioural counselling, group therapy, pharmacotherapy or a combination of treatments that have been proven to be effective
  • tailored advice, counselling and support
  • pharmacotherapies – nicotine replacement therapy, varenicline or bupropion, as appropriate.
[Adapted from NICE guideline PH10, recommendations 2 and 4]

Equality and diversity considerations

Smoking is significantly more prevalent among people in routine and manual occupations. Targeting businesses that employ large numbers of people who work in routine and manual jobs has a potential to make a substantial difference.
Reducing smoking among people who are not employed is not specifically addressed by current guidelines, but smoking prevalence in this group is high. ‘Stop smoking’ services, Job Centre Plus and other organisations working with people who are unemployed have an opportunity to work together to enable people who are not employed to access ‘stop smoking’ services.

Healthcare services: employee contracts

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Healthcare services use contracts that do not allow employees to smoke during working hours or when recognisable as an employee.

Rationale

Healthcare services have a duty of care to protect the health of people who use or work in their services and to promote healthy behaviour among these groups. Healthcare services set an example to the wider community and ensure that ‘no smoking’ is the norm. Using contracts that do not allow employees (including contractors and volunteers) to smoke during working hours or when recognisable as an employee, reflects the services’ commitment to implementing and enforcing a smokefree policy.

Quality measures

Structure
Evidence of arrangements within healthcare services to use employee contracts (including contractor and volunteer contracts) that do not allow smoking during working hours or when recognisable as an employee.
Data source: Local data collection.
Process
Proportion of healthcare services that use employee contracts (including contractor and volunteer contracts) that do not allow smoking during working hours or when recognisable as an employee.
Numerator – The number in the denominator that use employee contracts (including contractor and volunteer contracts) that do not allow smoking during working hours or when recognisable as an employee.
Denominator – The number of healthcare services in the specified geographic area.
Data source: Local data collection.
Outcome
Staff, contractors and volunteers found smoking during working hours or when recognisable as an employee.
Data source: Local data collection.

What the quality statement means for directors and senior managers of healthcare services or their representatives, commissioners and people who work in healthcare services

Directors and senior managers of healthcare services or their representatives ensure that contracts that do not to allow smoking during working hours or when recognisable as an employee are used and enforced for all employees (including contractors and volunteers).
Commissioners ensure that they commission healthcare services that use and enforce employee contracts (including contractor and volunteer contracts) that do not allow smoking during working hours or when recognisable as an employee.
People who work in healthcare services (including contractors and volunteers) do not smoke during working hours or when recognisable as an employee as set out in their contracts.

What the quality statement means for patients and visitors

Patients and visitors of healthcare services are in a setting in which employees (including contractors and volunteers) do not smoke.

Source guidance

Definitions of terms used in this quality statement

Healthcare services
All publicly funded community, primary, secondary and tertiary healthcare services. [Adapted from NICE guideline PH48 and NICE guideline PH10]

Healthcare settings: smokefree grounds

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Healthcare settings do not allow smoking anywhere in their grounds and remove any areas previously designated for smoking.

Rationale

Healthcare services have a duty of care to protect the health of people who use or work in their services and to promote healthy behaviour among these groups. Healthcare settings set an example to the wider community and ensure that ‘no smoking’ is the norm. Many healthcare services already have a smokefree policy in place, which includes smokefree grounds. However, some still facilitate smoking in their grounds by providing outdoor smoking areas, such as smoking shelters or designated smoking points.

Quality measures

Structure
Evidence of arrangements within healthcare settings to operate smokefree grounds and remove any areas previously designated for smoking.
Data source: Local data collection.
Process
a) Proportion of healthcare settings that do not allow smoking anywhere in their grounds.
Numerator – The number in the denominator that do not allow smoking anywhere in their grounds.
Denominator – The number of healthcare settings in the specified geographic area.
Data source: Local data collection.
b) Proportion of healthcare settings with no designated smoking areas.
Numerator – The number in the denominator with no designated smoking areas.
Denominator – The number of healthcare settings in the specified geographic area.
Data source: Local data collection.

What the quality statement means for directors and senior managers of healthcare services or their representatives, commissioners and people who work in healthcare services

Directors and senior managers of healthcare settings or their representatives ensure that smoking is not allowed anywhere in the grounds of healthcare settings. They ensure that the smokefree policy applies to anyone using the premises for any purpose at any time. They should also remove any areas in the grounds previously designated for smoking.
Commissioners ensure that their contracts with healthcare services include smokefree grounds and removal of any existing areas designated for smoking in the grounds.
People who work in healthcare services (including contractors and volunteers) are not allowed to smoke anywhere in the grounds of their healthcare setting. The setting does not have any areas set aside for smoking.

What the quality statement means for patients and visitors

Patients and visitors of healthcare settings are not allowed to smoke anywhere in the grounds of the healthcare setting.

Source guidance

Definitions of terms used in this quality statement:

Healthcare settings
All publicly funded community, primary, secondary and tertiary healthcare facilities, including buildings, grounds and vehicles.

Equality and diversity considerations

People who are unable to leave the healthcare setting because of disability, vulnerability or detention under the Mental Health Act will have to abstain from smoking, unlike other people who can leave the grounds to smoke if they wish. Additional support should be provided for people unable to leave the healthcare setting, as defined in NICE guideline PH48.

Healthcare settings: nicotine-containing products and stop smoking pharmacotherapies

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Secondary healthcare settings ensure that a range of licensed nicotine containing products and stop smoking pharmacotherapies is available on site for patients, visitors and employees.

Rationale

Secondary healthcare services have a duty of care to protect the health of people who use or work in their services and promote healthy behaviour among these groups. Most secondary and tertiary healthcare settings already have a smokefree policy in place, which includes smokefree grounds. Facilitating abstinence (long term or temporary) among patients, visitors and employees (including contractors and volunteers) will help ensure compliance with smokefree policies.

Quality measures

Structure
a) Evidence of local arrangements to ensure that ‘stop smoking’ pharmacotherapies and licensed nicotine containing products are stocked by pharmacies within secondary healthcare services.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that a range of licensed nicotine containing products is available for sale within secondary healthcare services for visitors and employees.
Data source: Local data collection
Process
a) Proportion of secondary healthcare settings that stock pharmacotherapies and licensed nicotine containing products.
Numerator – The number in the denominator that stock pharmacotherapies and licensed nicotine containing products.
Denominator – The number of secondary healthcare settings in the specified geographic area.
Data source: Local data collection.
b) Proportion of secondary healthcare settings that sell nicotine containing products to visitors and employees.
Numerator – The number in the denominator that sell nicotine containing products to visitors and employees.
Denominator – The number of secondary healthcare settings in the specified geographic area.

What the quality statement means for directors and senior managers of secondary care services or their representatives, commissioners and people who work in secondary healthcare services

Directors and senior managers of secondary care services or their representatives ensure that compliance with a smokefree policy is facilitated by a range of licensed nicotine containing products and ‘stop smoking’ pharmacotherapies being available on site for patients, visitors and employees.
Commissioners ensure that their contracts with secondary healthcare settings facilitate compliance with a smokefree policy by including on site provision of licensed nicotine containing products and ‘stop smoking’ pharmacotherapies for patients, visitors and employees.
People who work in secondary healthcare services (including contractors and volunteers) are helped to stick to the smokefree policy by being able to obtain a range of licensed nicotine containing products and ‘stop smoking’ therapies on site.

What the quality statement means for patients and visitors

Patients in secondary healthcare services can obtain a range of licensed nicotine containing products and ‘stop smoking’ pharmacotherapies onsite at all times. This helps them follow the smokefree policy within the healthcare grounds.
Visitors can obtain a range of licensed nicotine containing products onsite at all times. This helps them follow the smokefree policy within the healthcare grounds.

Source guidance

Definitions of terms used in this quality statement

Secondary healthcare settings
All publicly funded secondary health and tertiary care facilities, including buildings, grounds and vehicles. This includes drug and alcohol services in secondary care, emergency care, inpatient, residential and long term hospital care for severe mental illness, psychiatric and specialist units and secure hospitals, and planned specialist medical care or surgery. It also includes maternity care provided in hospitals, maternity units, outpatient clinics and in the community. Care can be planned or emergency care. Planned secondary care generally follows a referral from a primary care provider, such as a GP. [NICE guideline PH48]
Licensed nicotine-containing products
Licensed nicotine containing products are a safe and effective way of reducing the amount people smoke. They can be used as a complete or partial substitute for tobacco, either in the short or long term.
Some nicotine containing products are not regulated by the Medicines and Healthcare products Regulatory Agency (MHRA) and, therefore, their effectiveness, safety and quality cannot be assured. These products are likely to be less harmful than cigarettes. For further details, see the MHRA website.
Different forms of nicotine containing products include:
  • patches
  • gum
  • inhalator
  • lozenges
  • nasal spray.
If alternative nicotine containing products (such as e cigarettes) gain licensing authorisation in the future, this quality statement will be reviewed.
‘Stop smoking’ pharmacotherapies
Pharmacotherapy is the treatment of addiction through the administration of drugs. ‘Stop smoking’ advisers and healthcare professionals may recommend and prescribe licensed nicotine containing products, varenicline or bupropion, as an aid to help people to stop smoking. Licensed nicotine containing products may also be offered to support temporary abstinence from smoking in the secondary healthcare setting.

Equality and diversity considerations

People whose drug treatment is affected by smoking may need to have the dosage of their drugs adjusted. This is particularly important for people with mental health problems taking antipsychotic medication.

Media campaigns

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Local authorities use regional and local media channels to reinforce national tobacco reduction campaigns.

Rationale

There is evidence that social marketing and media campaigns can stop people from taking up smoking and can be effective in changing smoking behaviour in those who already smoke. National campaigns that aim to reduce smoking in the community are run on a regular basis by the Department of Health and Public Health England. These should be communicated to local authorities in advance so that the campaign messages can be promoted and reinforced regionally and locally by all partners working together on tobacco control.

Quality measures

Structure
a) Evidence of local authorities using regional or local media channels to reinforce messages from national tobacco reduction campaigns.
Data source: Local data collection.
b) Evidence of regional and local activities to reinforce national tobacco reduction campaigns.
Data source: Local data collection.

What the quality statement means for local authorities and Public Health England

Local authorities supported by Public Health England use regional and local media channels to reinforce messages from national tobacco reduction campaigns. They may work in partnership to commission regional providers to improve cost effectiveness and consistency of the messages.

What the quality statement means for adults, children and young people

Adults, children and young people come into contact with campaign messages that put them off taking up smoking and encourage them to quit if they already smoke.

Source guidance

Definitions of terms used in this quality statement

Reinforcing national tobacco reduction campaigns locally
Reinforcing national tobacco reduction campaigns locally is likely to include some or all of the following:
  • Production and dissemination of local press releases.
  • Completion of radio and television interviews.
  • Delivery of local promotional events in community settings, for example, sports stadia, supermarkets, shopping centres and markets.
  • Production and dissemination of e information and e mail footers.
  • Dissemination of information through social media streams.
[NICE guideline PH14 and expert opinion]

Equality and diversity considerations

Smoking is more common in socially deprived areas and among people in routine and manual jobs. When developing campaigns, consideration should be given about how to target these groups, with what messages and via which media. Local campaigns should use local intelligence to tailor the activities so that they are effective for the local population.

Illicit tobacco: placeholder statement

This quality statement is taken from the smoking: reducing tobacco use quality standard. The quality standard defines clinical best practice in smoking: reducing tobacco use and should be read in full.

Quality statement

Preventing access to, demand for and supply of, illicit tobacco.

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence based guidance to be developed in this area.

What is illicit tobacco?

  • Cigarettes
    • ‘Illicit white’ cigarettes have no legal market in the UK. UK duty has not been paid and the appropriate health warnings and images may not be present. Some of these products may be legally sold in countries outside the UK.
    • Counterfeit cigarettes are illegally manufactured and sold by a party other than the original trademark or copyright holder. This can also include the counterfeiting of ‘illicit white’ cigarettes.
  • Genuine cigarettes intended for sale in another country may have been smuggled into the UK or duty free cigarettes may be sold illegally rather than kept for personal use.
  • Hand rolling tobacco
    • Non UK hand rolling tobacco brands are not intended for sale in the UK.
    • Counterfeit hand rolling tobacco is, like cigarettes, illegally manufactured and sold by a party other than the original trademark or copyright owner. It can also include the counterfeiting of non UK products. Genuine or UK hand rolling tobacco brands include products intended for both the UK and non UK markets. [Tackling illicit tobacco for better health]

Rationale

Illicit tobacco products make tobacco more accessible to children and young people, and those from socioeconomic groups already experiencing significant health inequalities. Illicit tobacco products are often half or a third of the price of duty paid products and can be accessed from a wide range of unregulated suppliers. Preventing children and young people and adults from accessing illicit tobacco is likely to have a significant effect on the rates of smoking and smoking uptake.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this pathway is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the pathway to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Technology appraisals

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this pathway is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the pathway does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

A carbon monoxide assessment is a non-invasive biochemical method for measuring CO from expired breath. It can detect exposure to CO which may come from tobacco smoke, traffic emissions or leaky gas appliances.
A formulary is a list of healthcare treatments and drugs approved for use within a health economy, service or organisation.
Intensive interventions typically involve scheduled face-to-face meetings between someone who smokes, either alone or in a group, and a counsellor trained to provide stop smoking support. The discussions may include information, practical advice about goal-setting, self-monitoring and dealing with the barriers to stopping smoking as well as encouragement. Intensive behavioural support also includes anticipating and dealing with the challenges of stopping. Established and effective behaviour-change techniques should be used (see NICE public health guidance on Behaviour change). Support is typically offered weekly for at least the first 4 weeks of a quit attempt (that is, for 4 weeks after the quit date) or 4 weeks after discharge from hospital (where a quit attempt may have started before discharge), and normally given with stop smoking pharmacotherapy.
A joint strategic needs assessment provides a profile of the health and social care needs of a local population. Joint strategic needs assessments are used to develop joint health and wellbeing strategies. They are also used for commissioning to improve health outcomes and reduce health inequalities.
Nicotine-containing products that are licensed have been given marketing authorisation by the Medicines and Healthcare products Regulatory Agency (MHRA). At the time of publication (November 2013), nicotine replacement therapy (NRT) products were the only type of licensed nicotine-containing product. However, the MHRA has decided that all nicotine-containing products should be regulated and this is expected to come into effect in 2016. In the meantime, the UK government will encourage applications for medicines licences for nicotine-containing products and will make best use of the flexibilities within the existing framework to enable licensed products to be available. For further details, see the MHRA website.
Products that contain nicotine but do not contain tobacco and so deliver nicotine without the harmful toxins found in tobacco. Some, such as nicotine replacement therapy (NRT), are regulated by the MHRA (see licensed nicotine-containing products). Unlicensed products that are currently being marketed, such as electronic cigarettes, and products new to the market will need a medicines licence once the European Commission's revised Tobacco Products Directive comes into effect in the UK (this is expected to be in 2016). For further details, see the MHRA website.
Nicotine replacement therapy are licensed nicotine-containing products for use as a stop smoking aid and for temporary abstinence, as outlined in the British national formulary. They include: transdermal patches, gum, inhalation cartridges, sublingual tablets and a mouth and nasal spray.
Pharmacotherapy is the treatment of addiction through the administration of drugs. Stop smoking advisers and healthcare professionals may recommend and prescribe licensed nicotine-containing products, varenicline or bupropion as an aid to help people to stop smoking. Licensed nicotine-containing products may also be offered to support temporary abstinence from smoking in the secondary care setting.
Secondary care refers to all publicly-funded secondary and tertiary care facilities, including buildings, grounds and vehicles. It covers drug and alcohol services in secondary care, emergency care, inpatient, residential and long-term care for severe mental illness in hospitals, psychiatric and specialist units and secure hospitals and planned specialist medical care or surgery. It also includes maternity care provided in hospitals, maternity units, outpatient clinics and in the community. It can be planned or emergency care. Planned secondary care generally follows a referral from a primary care provider, such as a GP.
Smokefree means air that is free of smoke and applies to hospital buildings, grounds and vehicles.
Stopping smoking with the intention to stop permanently. Stopping may be abrupt or by cutting down before stopping.
Stop smoking services provide a combination of behavioural support and pharmacotherapy to aid smoking cessation. NHS behavioural support is free but the pharmacotherapy may incur a standard prescription charge. The evidence-based treatment is based on the National Centre for Smoking Cessation and Training (NCSCT) standard programme and involves practitioners trained to their standard or equivalent.
Not smoking for a limited period of time. This could be for a particular event, for example, during a hospital stay or contact with secondary care providers, or in preparation for planned use of secondary care services such as elective surgery, or while visiting or working in a secondary care setting.

Paths in this pathway

Pathway created: November 2013 Last updated: August 2015

© NICE 2016

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