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Smoking
Short Text
Introduction
This pathway covers interventions and strategies to prevent children and young people from taking up smoking and to help everyone who already smokes to quit. This includes tailored strategies for women who are pregnant or who have recently given birth. It also includes strategies to help adults who smoke who are from a disadvantaged background and, hence, most at risk of dying prematurely.
Activities could take place in a range of places, including workplaces and schools.
Smoking cessation interventions are generally very cost effective, irrespective of the target audience, the methods used to identify and recruit adults or the type of service offered.
Source guidance
The NICE guidance that was used to create the pathway.
Quitting smoking in pregnancy and following childbirth. NICE public health guidance 26 (2010)
School-based interventions to prevent smoking. NICE public health guidance 23 (2010)
Identifying and supporting people most at risk of dying prematurely. NICE public health guidance 15 (2008)
Preventing the uptake of smoking by children and young people. NICE public health guidance 14 (2008)
Smoking cessation services. NICE public health guidance 10 (2008)
Workplace interventions to promote smoking cessation. NICE public health guidance 5 (2007)
Brief interventions and referral for smoking cessation. NICE public health guidance 1 (2006)
Varenicline for smoking cessation. NICE technology appraisal 123 (2007)
Quality standards
Quality statements
Effective interventions library
Brief interventions
The interventions listed below are part of NICE's effective interventions library on public health. The evidence on these interventions was used to develop the recommendations in this pathway. All interventions listed have been identified and appraised using NICE public health methods and processes.
When reading the data, bear in mind that it has been interpreted in a review process, discussed by committee and considered in relation to a range of populations and different experiences in order to develop recommendations. In general, data on interventions is often limited: population studies are expensive to run; follow-up is generally short; studies may have been poorly conducted; reporting is variable and often poor. However, even when effects seem to be small, there can be enormous benefits when an intervention is applied across the whole population.
Where possible, the NICE analysts have calculated a measure of effectiveness from the original studies. These cases are marked 'i' (implied by the data).
Proactive recruitment to smoking cessation services
The interventions listed below are part of NICE's effective interventions library on public health. The evidence on these interventions was used to develop the recommendations in this pathway. All interventions listed have been identified and appraised using NICE public health methods and processes.
When reading the data, bear in mind that it has been interpreted in a review process, discussed by committee and considered in relation to a range of populations and different experiences in order to develop recommendations. In general, data on interventions is often limited: population studies are expensive to run; follow-up is generally short; studies may have been poorly conducted; reporting is variable and often poor. However, even when effects seem to be small, there can be enormous benefits when an intervention is applied across the whole population.
Where possible, the NICE analysts have calculated a measure of effectiveness from the original studies. These cases are marked 'i' (implied by the data).
Successful effective interventions library details
Brief advice from a physician
Key elements of the intervention
5 minutes of advice from a physician as a brief intervention.
Source guidance
Recommendation 3 from Brief interventions for smoking cessation (NICE public health guidance 1).
Effectiveness
For more details on the evidence below, see the NICE systematic review.
Lancaster and Stead (2004), international
Study design Meta-analysis
Final sample size Pooled data from 17 trials
Outcome Odds of quitting attributable to brief advice compared with no advice (or usual care)
Costs
For more details on the evidence below, see the NICE economic review.
Cummings et al. (1989) Costs from £37 to £89 per additional quitter. Using a discount rate of 5%, the cost per life year gained ranged from £50 to £122.
Akehurst 1994 Based on average cost-effectiveness, the cost was £296 per quitter, £6,838 per death avoided and £613 per life year gained.
Factors to take account of
Occasionally it might be inappropriate to advise a patient to quit, for example, because of their presenting condition or personal circumstancesFrom Brief interventions for smoking cessation, footnote in section 1..
Impact on health inequalities
The studies included in this systematic review did not report the socio-economic status of the patients. However, differences in the prevalence of smoking between the higher and lower social classes account for over half the difference in the risk of premature death faced by these groupsFrom Brief interventions for smoking cessation, section 2.2..
Structured advice from a nurse
Key elements of the intervention
Up to 10 minutes of structured advice from a nurse, and up to one follow-up visit.
Source guidance
Recommendation 4 from Brief interventions for smoking cessation (NICE public health guidance 1).
Effectiveness
For more details of the evidence below, see the NICE systematic review.
Rice et al. (2004), international
Study design Meta-analysis
Final sample size 6 trials
Outcome 12-month quit rate for nurse intervention compared with usual care
Measure of effect OR 1.76 (95% CI 1.23–1.53); numbers quitting with intervention 84/1282 (7%), control 49/1340 (4%); NNT 34 (i)
Costs
For more details on the evidence below, see the NICE economic review.
Krumholz (1993) Cost-effectiveness was estimated at $380 per quitter. The ICER was $220 per additional year of life saved.
Factors to take account of
Occasionally it might be inappropriate to advise a patient to quit, for example, because of their presenting condition or personal circumstancesFrom Brief interventions for smoking cessation, footnote in section 1..
Impact on health inequalities
The studies included in this systematic review did not report the socio-economic status of the patients. However, differences in the prevalence of smoking between the higher and lower social classes account for over half the difference in the risk of premature death faced by these groupsFrom Brief interventions for smoking cessation, section 2.2..
Nicotine-replacement therapy as part of a brief intervention
Key elements of the intervention
Nicotine-replacement therapy prescribed with low-intensity support.
Source guidance
Recommendation 3 from Brief interventions for smoking cessation (NICE public health guidance 1).
Effectiveness
For more details on the evidence below, see the NICE systematic review.
Silagy, Lancaster, Stead et al. (2002), international
Study design Meta-analysis
Sample Review of 34 randomised trials
Outcome 12-month quit rate
Measure of effectiveness Pooling gum and patch trials resulted in an OR of 1.81 (95% CI 1.61–2.02) compared with low-intensity support and placebo or no nicotine gum. This relative effect was comparable with that obtained with more intensive support. NNT 14 (i)
Costs
For more details on the evidence below, see the NICE economic review.
Akehurst (1994) The ICER of nicotine patches over and above GP counselling was £1252 per quitter, £58,894 per death avoided and £4526 per life year gained.
Stapleton (1999) The ICER of nicotine patches and brief GP advice over and above brief GP advice alone was £398 for patients aged under 35 years, £345 for patients aged 35–44 years, £432 for patients aged 45–54 years, and £785 for patients aged 55–65 years.
Factors to take account of
Occasionally it might be inappropriate to advise a patient to quit, for example, because of their presenting condition or personal circumstancesFrom Brief interventions for smoking cessation, footnote in section 1..
Impact on health inequalities
The studies included in this systematic review did not report the socio-economic status of the patients. However, differences in the prevalence of smoking between the higher and lower social classes account for over half the difference in the risk of premature death faced by these groupsFrom Brief interventions for smoking cessation, section 2.2..
Proactive recruitment using health records
Key elements of the intervention
Proactive recruitment of smokers from health records, followed by provision of advice and information.
Source guidance
Recommendation 1 from Identifying and supporting people most at risk of dying prematurely (NICE public health guidance 15).
Effectiveness
For more details of the evidence below, see the NICE systematic review.
Murray et al (2007), UK
Study design Cluster RCT
Final sample size 24 primary care practices; intervention group 3051, control 3805
Outcomes Proportion of smokers reporting attendance at local NHS stop smoking services, and number of quit attempts
Measure of effect Increased the proportion of smokers reporting attendance at stop smoking services and had a modest effect on the number of quit attempts made, but no significant impact on actual quit rates or reported cigarette consumption
Bentz et al (2006), USA
Study design Observational
Final sample size 15,662 smokers
Outcomes Numbers calling the quit line and accessing tobacco cessation services
Measure of effect 19% called the quit line. Of these, 94% accepted a one-time tobacco cessation intervention from a quit line counsellor
Glasgow et al. (2006), USA
Study design Cohort
Final sample size Study 1, 160; study 2, 531
Outcomes Reach of comprehensive programmes that include a smoking reduction component (rather than just cessation)
Measure of effect Reach increased by 22–39%
Costs
For more details of the evidence below, see the NICE economic review.
Murray et al. (2007) Cost per QALY £2,089 (2007 prices)
Bentz et al. (2006) Cost per QALY £365 (2007 prices)
Factors to take account of
Identifying and supporting people most at risk of dying prematurely summarises the factors NICE's committee considered when developing the recommendations on recruiting people to stop smoking interventions. See paragraphs 3.4–3.7.
Impact on health inequalities
Only Glasgow et al. (2006) reported the socio-economic status of patients, but there is limited discussion of any possible effect on outcomes – despite there being a higher proportion of non-participants with lower education levels.
Proactive recruitment of patients using a questionnaire
Key elements of the intervention
Proactive recruitment of smokers from a questionnaire of existing patients, followed by provision of advice and information.
Source guidance
Recommendation 1 from Identifying and supporting people most at risk of dying prematurely (NICE public health guidance 15).
Effectiveness
For more details of the evidence below, see the NICE systematic review.
Milch et al. (2004), USA
Study design Prospective cluster controlled trial (not randomised)
Final sample size Enhanced (questionnaire) 115, minimal (smoking status recorded) 118, control 411
Outcome Self-reported quit rates at mean follow up of 9.5 months
Measure of effect Enhanced 12% (14/115), minimal 2% (2/118), control 4% (17/411) (p<0.001); NNT 13 (i)
Costs
For more details of the evidence below, see the NICE economic review.
Milch et al. (2003a) Cost per QALY £11 (2007 prices)
Factors to take account of
Identifying and supporting people most at risk of dying prematurely summarises the factors NICE's committee considered when developing the recommendations on recruiting people to stop smoking interventions. See paragraphs 3.4–3.7.
Impact on health inequalities
The trial did not report the socio-economic status of the patients; however, differences in the prevalence of smoking between the higher and lower social classes accounts for over half the difference in the risk of premature death faced by these groupsFrom Brief interventions for smoking cessation, section 2.2..
Proactive recruitment as part of cervical screening
Key elements of the intervention
Proactive recruitment of smokers as part of routine cervical screening, followed by provision of advice and information.
Source guidance
Recommendation 1 from Identifying and supporting people most at risk of dying prematurely (NICE public health guidance 15).
Effectiveness
For more details of the evidence below, see the NICE systematic review.
Hall et al. (2003), UK
Study design Cluster RCT
Final sample size 242
Outcome Report of readiness to stop smoking in the next 6 months
Measure of effect Women sent a brief leaflet were more likely to report that they were ready to stop compared with those:
- sent an extended leaflet: 75% vs 46% (95% CI 11–48%); NNT 4
- not sent a leaflet: 75% vs 40% (95% CI 19–52%) NNT (i)
Hall et al. (2007), UK
Study design Cluster RCT
Final sample size Intervention 121, control 121
Outcome Intention to stop smoking in the next month, measured at 2 and 10 weeks
Measure of effect
- At 2 weeks: intervention 2.86 (SD 1.80), control 2.29 (SD 1.71), adjusted mean difference 0.51 (95% CI 0.02–1.03), p=0.06
- At 10 weeks: intervention 3.13 (SD 2.04), control 2.24 (SD 1.58), adjusted mean difference 0.80 (95% CI 0.10–1.50), p=0.03
Effect size at 10 week follow up 0.32 (i)
Costs
For more details of the evidence below, see the NICE economic review.
Hall et al. (2003) Cost per QALY £19 (2007 prices)
Hall et al. (2007) Cost per QALY £86 (2007 prices)
Factors to take account of
Identifying and supporting people most at risk of dying prematurely summarises the factors NICE's committee considered when developing the recommendations on recruiting people to stop smoking interventions. See paragraphs 3.4–3.7.
Impact on health inequalities
The study did not report the socio-economic status of the women who agreed to participate. But cervical screening involves the vast majority of women across all socio-economic groups within a certain age range on regular occasions, so this may be a useful way to draw young disadvantaged smokers into considering quitting. Further research with disadvantaged women is required to confirm thisFrom the NICE systematic review.
Proactive recruitment of parents
Key elements of the intervention
Proactive recruitment of smokers as part of their children's paediatric appointment followed, by provision of advice and information.
Source guidance
Recommendation 1 from Identifying and supporting people most at risk of dying prematurely (NICE public health guidance 15).
Effectiveness
For more details of the evidence below, see the NICE systematic review.
Curry et al. (2003), USA
Study design RCT
Final sample size Intervention 156, control 147
Outcome Self-reported quit rate
Measure of effect
- At 3 months: intervention 8%, control 3% (adjusted OR 2.40, 95% CI 0.85–7.80); NNT20 (i)
- At 12 months: intervention 14%, control 7% (adjusted OR 2.77, 95% CI 1.24–6.60 using an intention to treat analysis); NNT 15 (i)
Costs
For more details of the evidence below, see the NICE economic review.
Curry et al (2003) Cost per QALY £1126 (2007 prices)
Factors to take account of
Identifying and supporting people most at risk of dying prematurely summarises the factors NICE's committee considered when developing the recommendations on recruiting people to stop smoking interventions. See paragraphs 3.4–3.7.
Impact on health inequalities
Curry et al (2003) identified female smokers accompanying children to paediatric visits in clinics that serve an ethnically diverse population of low income families.
Proactive recruitment at AIDS and HIV clinics
Key elements of the intervention
Proactive recruitment of smokers as part of routine AIDS/HIV clinic appointment, followed by provision of advice and information
Source guidance
Recommendation 1 from Identifying and supporting people most at risk of dying prematurely (NICE public health guidance 15).
Effectiveness
For more details of the evidence below, see the NICE systematic review.
Vidrine et al. (2006), USA
Study design Observational pilot study
Final sample size 49
Outcome Abstinence (not smoking in 24 hours before assessment) and sustained abstinence (not smoking in 7 days before assessment) at 3 months
Measure of effect
- Abstinence: intervention 29.2% (intervention delivered by cell phone), control 8.5% (usual care) (p=0.040); NNT 5 (i)
- Sustained abstinence: intervention 16.7%, control 6.4% (p=0.283); NNT 10 (i)
Costs
For more details of the evidence below, see the NICE economic review.
Vidrine et al. (2006) Cost per QALY £175 (2007 prices)
Factors to take account of
Identifying and supporting people most at risk of dying prematurely summarises the factors NICE's committee considered when developing the recommendations on recruiting people to stop smoking interventions. See paragraphs 3.4–3.7.
Impact on health inequalities
Lazev et al. (2004) explore barriers to participating in smoking cessation programmes among low income, HIV-positive smokers.
Vidrine et al. (2006) point out that the clinic served an ethnically/racially diverse population of economically disadvantaged people.
Implementation
Assessment tools
The baseline and self-assessment tools are Excel spreadsheets that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.
Audit support
Audit support provides ready-to-use criteria, including exceptions, definitions, suggested data sources and a data collection tool.
Commissioning guides
Commissioning guides provide information on key clinical and service-related issues to consider during the commissioning process. Each guide contains a commissioning and benchmarking tool, which is a resource that can be used to estimate and inform the level of service needed locally as well as the cost of local commissioning decisions.
Costing support
Costing support includes national cost impact reports that summarise the national costs and savings and discuss the assumptions used; costing templates to assess the impact on local budgets; and costing statements when the impact is not significant or impossible to quantify at a national level.
Education tools
NICE has developed online learning modules, in collaboration with a range of providers, including BMJ Learning, to update knowledge on evidence and NICE guidance.
Service planning
Providing implementation advice, these tools help people to plan or deliver services. They can include an overview of the key steps and decision points in the care pathway and suggestions for putting the guidance into practice locally.
Slide sets
Slide sets provide a framework for discussion and assist in local dissemination of the guidance. The slides contain the key messages from NICE guidance and can be tailored for local presentations.
Pathway information
Health inequalities
Reducing the prevalence of smoking among people in routine and manual groups, some minority ethnic groups and disadvantaged communities will help reduce health inequalities more than any other measure to improve the public's health.
Although NHS Stop Smoking Services have helped large numbers of people to quit smoking, smoking cessation rates are still lower among people in routine and manual groups compared with those in higher socioeconomic groups. In particular, pregnant women in routine and manual groups and those aged 20 or under may need additional support to give up smoking.
Health inequalities are so deeply entrenched that providing disadvantaged groups or areas with better services – and better access to those services – can only be one element of a broader strategy to address the distribution of the wider determinants of health. All activities need to be developed and sustained on a long-term basis.
Pregnant women
Helping pregnant women who smoke to quit involves communicating in a sensitive, client-centred manner, particularly as some pregnant women find it difficult to say that they smoke. Such an approach is important to reduce the likelihood that some of them may miss out on the opportunity to get help.
Mass-media and point-of-sale measures
Mass-media and point-of-sales measures should be combined with other prevention activities as part of a comprehensive tobacco control strategy. Such a strategy is defined by the US Surgeon General, World Health Organization and others as encompassing price and regulation policies, education programmes, cessation support services and community programmes. It should be sufficiently extensive and sustained to have a reasonable chance of success.
Workplace interventions
Reducing smoking and tobacco-related harm is a key government strategy for improving the health of people in England and reducing health inequalities. Since July 2007, smoking has been prohibited in virtually all enclosed public places and workplaces in England. This includes vehicles used for business and any rooms or shelters previously set aside for smoking (if they are enclosed or substantially enclosed, according to the definition of the law). Failure to comply is an offence.
Employers are not legally obliged to help employees to stop smoking. However, those that do provide cessation support could reduce the risk of non-compliance with the law, as well as taking advantage of the opportunity it offers to improve people's health. They will be promoting healthy living and no smoking within society, as well as benefiting from reduced sickness absence and increased productivity.
Updates to this pathway
25 October 2011 Minor maintenance updates
31 January 2012 Clarification of when to use a CO breath test added to referring women from maternity services to evidence-based stop smoking services.
14 May 2012 Effective interventions library information added to system incentives to improve the health of people who are disadvantaged and primary care health practitioners.
26 September 2012 Added link to the Smokeless tobacco cessation: South Asian communities pathway to the overview.
Supporting information
Glossary
Brief interventions (also known as brief advice) to help people stop smoking involve opportunistic advice, discussion, negotiation or encouragement and, where necessary, referral to more intensive treatment. They are delivered by a range of professionals, typically in less than 10 minutes.
The package provided depends on a number of factors including someone's willingness to quit, how acceptable they find the intervention and previous methods they have used. It may include one or more of the following:
- simple opportunistic advice
- an assessment of the person's commitment to quit
- pharmacotherapy and/or behavioural support
- self-help material
- referral to more intensive support such as evidence-based stop smoking services.
Cardiovascular disease (CVD) is generally due to reduced blood flow to the heart, brain or body caused by atheroma or thrombosis. Plaques (plates) of fatty atheroma build up in different arteries during adult life. These can eventually cause narrowing of the arteries, or trigger a local thrombosis (blood clot) which completely blocks the blood flow. The main types of CVD are: coronary heart disease (CHD), stroke and peripheral arterial disease (PVD).
Confidence interval. There is always some uncertainty in research. This is because a small group of people is studied to predict the effects of an intervention on the wider population. The confidence interval is a way of expressing how certain we are about the findings from a study, using statistics. It gives a range of results that is likely to include the 'true' value for the population.
The CI is usually stated as '95% CI', which means that the range of values has a 95 in a 100 chance of including the 'true' value. For example, a study may state that 'based on our sample findings, we are 95% certain that the 'true' population blood pressure is not higher than 150 and not lower than 110'. In such a case the 95% CI would be 110 to 150.
A wide confidence interval indicates a lack of certainty about the true effect of the test or treatment – often because a small group of patients has been studied. A narrow confidence interval indicates a more precise estimate (for example, if a large number of patients have been studied).
Adults who are disadvantaged include (but are not limited to):
- those on a low income (or who are members of a low-income family)
- those on benefits
- those living in public or social housing
- some members of black and minority ethnic groups
- those with a mental health problem
- those with a learning disability
- those who are institutionalised (including those serving a custodial sentence)
- those who are homeless.
Effect size. A measure that shows the magnitude of the outcome in one group compared with that in a control group.
For example, if the absolute risk reduction is shown to be 5% and it is the outcome of interest, the effect size is 5%.
The effect size is usually tested, using statistics, to find out how likely it is that the effect is a result of the treatment and has not just happened by chance (that is, to see if it is statistically significant).
NICE analysts have calculated this figure using data from the original study.
Local agencies define disadvantaged areas in a variety of ways. An example is the 'Index of Multiple Deprivation 2007'. This combines indicators on economic, social and housing issues to produce a single deprivation score.
Incremental cost effectiveness ratio. A measure of the cost effectiveness of a treatment or health intervention. It estimates how much more the benefits of a certain treatment cost, compared with other treatments or health interventions.
Number needed to treat. The average number of people who need to receive an intervention to get a positive outcome. For example, if the NNT is four, then 4 people would have to receive the intervention to ensure one of them gets better. The closer the NNT is to one, the better the intervention. However, as with most data, caution is needed when considering whether results apply to populations beyond the sample described in the original study.
Local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. The professionals involved may include midwives who have been specially trained to help pregnant women who smoke to quit.
Odds ratio. Odds are a way to represent how likely it is that something will happen (the probability). An odds ratio compares the probability of something in one group with the probability of the same thing in another.
An odds ratio of 1 between two groups would show that the probability of the event (for example a person developing a disease, or an intervention working) is the same for both.
Sometimes probability can be compared across more than two groups – in this case, one of the groups is chosen as the 'reference category', and the odds ratio is calculated for each group compared with the reference category. For example, to compare the risk of dying from lung cancer for non-smokers, occasional smokers and regular smokers, non-smokers could be used as the reference category. Odds ratios would be worked out for occasional smokers compared with non-smokers and for regular smokers compared with non-smokers.
Group behaviour therapy programmes involve weekly meetings for the first 4 weeks of a quit attempt. During these meetings, people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy) delivered over at least two sessions. See 'Individual behavioural counselling for smoking cessation'.
This is a face-to-face encounter between someone who smokes and a counsellor trained in smoking cessation.
Quality-adjusted life year. A measure of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life. One QALY is equal to 1 year of life in perfect health.
QALYS are calculated by estimating the years of life remaining for a person following a particular treatment or intervention and weighting each year with a quality of life score (on a zero to one scale). It is often measured in terms of the person's ability to perform the activities of daily life, freedom from pain and mental disturbance.
Mass-media interventions use a range of methods to communicate a message. This can include local, regional or national television, radio and newspapers, and leaflets and booklets. It can also include new media.
In this pathway, 'new media' refers to communication via the Internet or mobile phone.
On the Internet, it can involve anything from real-time streaming of information and podcasts, to discussions with experts and the use of social networking sites. (An example of real-time streaming of information is the 'breaking news' text that appears along the bottom of the screen during some TV news programmes.)
The aim of mass-media interventions is to reach large numbers of people without being reliant on face-to-face contact.
Randomised controlled trial. A study in which a number of similar people are randomly assigned to two (or more) groups to test a specific drug or intervention. One group (the experimental group) receives the intervention being tested, the other (the comparison or control group) receives an alternative intervention, a dummy intervention (placebo) or no intervention at all. The groups are followed up to see how effective the experimental intervention was. Outcomes are measured at specific times and any difference in response between the groups is assessed statistically. This method is also used to reduce bias.
Stop smoking advisers and healthcare professionals may recommend and prescribe nicotine replacement therapy (NRT), varenicline or bupropion as an aid to help people to quit smoking, along with giving advice, encouragement and support.
Before prescribing a treatment, they take into account the person's intention and motivation to quit and how likely it is they will follow the course of treatment. They also consider which treatments the individual prefers, whether they have attempted to stop before (and how), and if there are medical reasons why they should not be prescribed NRT, varenicline or bupropion.
Standard deviation. A measure used to summarise numerical data and describe how 'spread out' a set of measures (or 'values') are from the average. For example, the average height of a group of schoolchildren can be calculated using the total of all their heights added together and then divided by the number of schoolchildren in the group. Standard deviation measures the 'spread' of those heights. So, in the example it tells you whether all those in the group were about the same height or whether some were very tall and some were short.
Point-of-sales interventions take place at the point where tobacco could be sold. Primarily, they aim to deter shopkeepers from making illegal sales.
In this pathway 'Schools' is used to refer to the following educational establishments:
- 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.
Self-help materials comprise any manual or structured programme, in written or electronic format, that can be used by individuals in a quit attempt without the help of health professionals, counsellors or group support. Materials can be aimed at anyone who smokes, particular populations (for example, certain age or ethnic groups) or may be interactively tailored to individual need. See Self-help interventions for smoking cessation.
Telephone counselling and quitlines provide proactive or reactive advice, encouragement and support over the telephone to anyone who smokes who wants to quit, or who has recently quit.
Strategy, policy and commissioning
Recommendations for strategy, policy and commissioning for smoking prevention and cessation
General
General education campaigns aimed at everyone
General education campaigns aimed at everyone
Coordinate communications strategies to support the delivery of smoking cessation services, telephone quitlines, school-based interventions, 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, 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
- be developed and evaluated using audience research
- use 'why to' and 'how to' quit messages that are non-judgemental, 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.
Source guidance
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Mass media campaigns for under-18s
Mass-media campaigns for under-18s
Context
Mass-media interventions use a range of methods to communicate a message. This can include local, regional or national television, radio and newspapers, and leaflets and booklets. It can also include new media. In this pathway, 'new media' refers to communication via the Internet or mobile phone. On the Internet, it can involve anything from real-time streaming of information and podcasts, to discussions with experts and the use of social networking sites. (An example of real-time streaming of information is the 'breaking news' text that appears along the bottom of the screen during some TV news programmes.) The aim of mass-media interventions is to reach large numbers of people without being reliant on face-to-face contact.
Point-of-sales interventions take place at the point where tobacco could be sold. Primarily, they aim to deter shopkeepers from making illegal sales.
Campaign development
Develop national, regional or local mass-media campaigns to prevent the uptake of smoking among young people under 18. The campaigns should:
- be informed by research that identifies and understands the target audiences
- consider groups which epidemiological data indicate have higher than average or rising rates of smoking
- be developed in partnership with: national, regional and local government and non-governmental organisations, the NHS, children and young people, media professionals (using their best practice), healthcare professionals, public relations agencies and local anti-tobacco activists.
The campaign(s) should not be developed in conjunction with the tobacco industry.
Campaign messages
Convey messages based on strategic research and qualitative pre- and post-testing with the target audiences. These could include messages that:
- elicit a strong, negative emotional reaction (for example, loss, disgust, fear) while providing sources of further information and support
- portray tobacco as a deadly product, not just as a drug that is inappropriate for children and young people to use
- use personal testimonials that children and young people can relate to
- are presented by celebrities to whom children and young people can relate (taking care to avoid credibility and other problems)
- empower children and young people to refuse offers of cigarettes
- include graphic images portraying smoking's detrimental effect on health as well as appearance (for example, its effect on the appearance of skin and teeth).
Repeat the messages in a number of ways and regularly update them to keep the audience's attention.
Campaign strategies
Use a range of strategies as part of any campaign to reduce the attractiveness of tobacco and contribute to changing society's attitude towards tobacco use, so that smoking is not considered the norm by any group. Strategies could include:
- generating news by writing articles, commissioning newsworthy research and issuing press releases
- using posters, brochures and other materials to promote the campaign
- using opportunities arising from new media.
The campaign(s) should not be delivered in conjunction with (or supported by) the tobacco industry.
National campaigns should exploit the full range of media used by children and young people, including television advertising.
Regional and local campaigns should build on, and be integrated with, a national communications strategy to tackle tobacco use. Regional campaigns should use regional press and radio (local campaigns should use local press and radio) to reach specific audiences and to get unpaid coverage in the press. They should also use regional and local networks (as appropriate) to generate as much publicity as possible.
Effective practice, including effective local and regional media messages, should be shared locally, regionally and nationally.
Campaigns should run for 3–5 years.
Use process and outcome measures to ensure campaigns are being delivered correctly and effectively. For recommendations on the principles of evaluation, see NICE guidance on behaviour change.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePrevention and cessation
Smoking prevention and cessation
Planning local services
Planning local, evidence-based stop smoking services
Planning local, evidence-based stop smoking services
Evidence-based provisionThis recommendation is from Smoking cessation services (NICE public health guidance 10)
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 evidence-based stop smoking services target minority ethnic and socioeconomically disadvantaged communities in the local population.
Ensure evidence-based 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 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.
Local targets and policy
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 commissioners of public health and health services.
Develop a policy to ensure that effective smoking cessation services are provided as part of the local tobacco control strategy.
Smokefree legislationThis recommendation is from Workplace interventions to promote smoking cessation (NICE public health guidance 5)
Ensure local evidence-based stop smoking services are able to respond to fluctuations in demand, particularly before and after implementation of smokefree legislation.
Services for hospitalsThis is part of a recommendation from Smoking cessation services (NICE public health guidance 10)
Commissioners of public health services should ensure that evidence-based 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. Commissioners of public health services should develop a clear referral plan with links between primary and acute trusts.
Reviewing policiesThis recommendation is from Brief interventions and referral for smoking cessation (NICE public health guidance 1)
NHS hospital trusts, commissioners of public health services, community pharmacies, local authorities and local community groups should review smoking cessation policies and practices to take account of the recommendations in this pathway.
See also recommendations for evidence-based stop smoking services and quitlines in this pathway.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleAdults who are disadvantaged
Helping adults who are disadvantaged to quit smoking
Helping adults who are disadvantaged to quit smoking
Accessible supportThis recommendation is from Brief interventions and referral for smoking cessation (NICE public health guidance 1)
Smoking cessation advice and support should be available in community, primary and secondary care settings for everyone who smokes. Local policy makers and commissioners should target hard to reach and deprived communities, including minority ethnic groups, paying particular attention to their needs.
Identifying adults at riskThis recommendation is from Identifying and supporting people most at risk of dying prematurely (NICE public health guidance 15)
Primary care professionals should use a range of methods to identify adults who are disadvantaged and at high risk of premature death from cardiovascular disease (CVD). These include:
- primary care and general practice registers (for example, to identify adults who smoke; who are from particular minority ethnic groups; or who have family members who have had premature coronary heart disease)
- primary care appointments (for example, during routine visits and screening)
- systematic searches in pre-identified areas or with specific populations (for example, using direct mail or telephone)
- analyses of quality and outcomes framework (QOF) data.
Those working with communities should use a range of methods to identify adults who are disadvantaged and at high risk of CVD. Methods to use include:
- health sessions run at a range of community and public sites, including post offices, charity shops, supermarkets, community pharmacies, homeless centres, workplaces, prisons and long-stay psychiatric institutions. (Lifestyle factors such as smoking or other indicators, such as blood pressure, could be used to identify those at risk)
- culturally sensitive education sessions that include a CVD risk assessment and which take place in black and minority ethnic community settings (including places of worship)
- outreach activities provided by community health workers (including health trainers).
Partnership working
Who should take action?
Planners, commissioners of public health services and service providers with a remit for tackling health inequalities. This includes general practices, community services, local partnerships, local authorities (including education and social services), the criminal justice system and members of the voluntary and business sectors.
What action should they take?
Develop and sustain partnerships with professionals and community workers who are in contact with people who are disadvantaged. Use joint strategic needs assessments, local partnerships, the GP contract and other mechanisms. For recommendations on community engagement see NICE guidance on community engagement to improve health.
Establish relationships between primary care practitioners and the community to understand how best to identify and help adults who are disadvantaged to adopt healthier lifestyles. For example, they should jointly determine how best to support health initiatives delivered as part of a local neighbourhood renewal strategy.
Establish relationships with secondary care professionals (for example, those working in respiratory medicine and CVD clinics) to help identify patients at high risk of further cardiovascular events. Offer these patients support or refer them on, where appropriate.
Develop and maintain a database of local initiatives that aim to reduce health inequalities by improving the health of people who are disadvantaged.
Develop and sustain local and national networks for sharing local experiences. Ensure mechanisms are in place to evaluate and learn from these activities on a continuing, systematic basis.
Ensure those working in the healthcare, community and voluntary sectors coordinate their efforts to identify people who need help.
Please also see recommendations for local authorities and health services on helping adults who are disadvantaged to quit smoking in this pathway.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleChildren and young people
Preventing children and young people from taking up smoking
Illegal sales
Illegal sales
Illegal sales
National policy
Support better enforcement of existing legislation by:
- working with the Local Better Regulation Office to make illegal tobacco sales a higher priority for local authorities, thereby increasing inspection and enforcement activities
- encouraging and providing all local authorities with support to:
- enforce legislation to prevent under-age tobacco sales, in accordance with their statutory role and best practice
- undertake regular audits of test purchasing to ensure consistent practice and enforcement
- encouraging national organisations and local authorities to provide education and training programmes for trading standards officers
- working with government agencies and national organisations to ensure retailers and others, such as publicans, are aware of legislation on under-age tobacco sales (including the fact that it covers vending machines)
- ensuring magistrates are aware of the:
- potential damage that smoking can do to children and young people and hence, the need to deter non-compliance among retailers
- range of measures available to deter retailers from making under-age tobacco sales, including the use of fines up to level four on the standard scale and the granting of either a 'restricted premises' or 'restricted sales order' (Criminal Justice and Immigration Act).
Ensure enforcement efforts are sustained over a number of years.
Local action
Ensure retailers are aware of legislation prohibiting under-age tobacco sales by:
- providing training and guidance on how to avoid illegal sales
- encouraging them to:
- request proof of age from anyone who appears younger than 18 who attempts to buy cigarettes and get it verified. (Examples of proof-of-age include a passport or driving licence or cards bearing the nationally-accredited 'PASS' hologram)
- complete the 'Age restricted products refusal register' for each tobacco sale refused on the grounds of age
- running campaigns to publicise the legislation. These could include details of possible fines that retailers can face, where tobacco is being sold illegally and successful local prosecutions, as well as health information.
Make it as difficult as possible for young people under 18 to get cigarettes and other tobacco products. In particular, exercise a statutory duty under the Children and Young Persons (protection from tobacco) Act 1991 to prevent under-age sales by:
- prosecuting retailers who persistently break the law
- taking enforcement action if tobacco vending machines are being used by children and young people under 18
- undertaking test purchases each year, using local data to detect breaches in the law and auditing them regularly to ensure consistent practice across all local authorities.
Ensure owners of vending machines and those who have them on their premises take all reasonable precautions to prevent under-age tobacco sales, in accordance with the law.
Give practical advice on how to avoid illegal sales via vending machines (for example, they should be located in places where they can easily be controlled or supervised). The National Association of Cigarette Machine Operators (NACMO) has issued guidance on the positioning of vending machines.
Work with other agencies to identify areas where under-age tobacco sales are a particular problem.
Work with the Local Better Regulation Office to improve inspection and enforcement activities related to illegal tobacco sales.
Assess whether an advocacy campaign is needed to support enforcement. Any such campaign should be run in accordance with best practice and provide a clear, published statement on how to deal with under-age tobacco sales.
Actively discourage use of enforcement and related campaigns developed by the tobacco industry.
Ensure efforts to reduce illegal tobacco sales by retailers are sustained.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeCoordinated approach in schools
Coordinated approach in schools
Coordinated approach in schools
Who should take action?
Government departments, school inspectorates, school governing bodies and school commissioners.
Children's trusts.
Local authorities, in particular, children and young people's services, trading standards and environmental health officers.
Connexions or Integrated Youth Support Services.
Commissioners of public health services.
Local tobacco control alliances.
What action should they take?
Ensure smoking prevention interventions in schools and other educational establishments are part of a local tobacco control strategy.
Ensure schools and other educational establishments deliver evidence-based smoking prevention interventions. These should be linked to their smokefree policy and consistent with regional and national tobacco control strategies.
Ensure the interventions are integrated into the curriculum, PSHE education and work associated with Healthy Further Education and Healthy Schools status. They should also follow the 'Healthy Schools enhancement model stage 5'. See also NICE guidance on behaviour change.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeSystem incentives
System incentives to improve the health of people who are disadvantaged
System incentives to improve the health of people who are disadvantaged
Support and sustain activities aimed at improving the health of people who are disadvantaged by:
- using relevant indicators to measure progress and compare performance across areas or organisations
- ensuring, wherever possible, that all targets aim to tackle health inequalities – and do not increase them
- ensuring exception-reporting does not increase health inequalities: commissioners of public health services should be provided with additional levers and tools to monitor and benchmark exception-reporting and to reduce persistent rates of exception coding
- considering the provision of comparative performance data to encourage providers to meet targets
- using local enhanced services to encourage providers and practitioners to identify and continue to support those who are at risk of premature death from cardiovascular disease (CVD) and other smoking-related diseases.
Provide incentives for local projects that improve the health of people who are disadvantaged, specifically those who smoke or are at high risk of CVD from other causes or are eligible for statins. Ensure the projects are evaluated and, if effective, ensure they continue.
Effective interventions library
Click on the links below for information from the evidence on interventions that were used to develop the recommendations in this part of the pathway. All interventions listed have been identified and appraised using NICE public health methods and processes.
When reading the data, bear in mind that it has been interpreted in a review process, discussed by committee and considered in relation to a range of populations and different experiences in order to develop recommendations. In general, data on interventions is often limited: population studies are expensive to run; follow-up is generally short; studies may have been poorly conducted; reporting is variable and often poor. However, even when effects seem to be small, there can be enormous benefits when an intervention is applied across the whole population.
Where possible, the NICE analysts have calculated a measure of effectiveness from the original studies. These cases are marked 'i' (implied by the data).
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
- Strategy, policy and commissioning for smoking prevention and cessation
- Smoking prevention and cessation in schools
- Smoking cessation in the workplace
- Local authority services to support smoking prevention and cessation
- Training in smoking prevention and cessation
- Evidence-based stop smoking services and quitlines
- Support from general NHS services to help people stop smoking
- Smoking prevention and cessation by community groups, the voluntary, independent and business sectors
- Smoking cessation in maternity services
- Referral pathway for pregnant women who smoke
Pathway created: May 2011 Last updated: September 2012
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