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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.
Recommendations for the NHS
Recommendations for the NHS on how to help people to stop smoking
Who should provide help
Who should provide help?
Prescribers of stop smoking drugs
Health practitioners who advise on or prescribe drugs to help people quit smoking
People who want to quit
Advice on quit smoking drugs for people who want to stop smoking (including young people)
Advice on quit smoking drugs for people who want to stop smoking (including young people)
Quit smoking drugsThis recommendation is from Smoking cessation services. NICE public heath guidance 10 (2007)
Offer nicotine replacement therapy (NRT), varenicline or bupropion, as appropriate, to people who are planning to stop smoking.
Offer advice, encouragement and support, including referral to an evidence-based stop smoking service, to help people in their attempt to quit.
NRT, varenicline or bupropion should normally be prescribed as part of an abstinent-contingent treatment, in which the smoker makes a commitment to stop smoking on or before a particular date (target stop date). The prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date. Normally, this will be after 2 weeks of NRT therapy, and 3-4 weeks for varenicline or bupropion, to allow for the different methods of administration and mode of action. Subsequent prescriptions should be given only to people who have demonstrated, on re-assessment, that their quit attempt is continuing.
Explain the risks and benefits of using NRT to young people aged from 12 to 17, pregnant or breastfeeding women, and people who have unstable cardiovascular disorders. To maximise the benefits of NRT, people in these groups should also be strongly encouraged to use behavioural support in their quit attempt.
Neither varenicline or bupropion should be offered to young people under 18 nor to pregnant or breastfeeding women.
Varenicline or bupropion may be offered to people with unstable cardiovascular disorders, subject to clinical judgement.
If a smoker's attempt to quit is unsuccessful using NRT, varenicline or bupropion, do not offer a repeat prescription within 6 months unless special circumstances have hampered the person's initial attempt to stop smoking, when it may be reasonable to try again sooner.
Do not offer NRT, varenicline or bupropion in any combination.
Consider offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past.
Do not favour one medication over another. The clinician and patient should choose the one that seems most likely to succeed.
When deciding which therapies to use and in which order, discuss the options with the client and take into account:
- whether a first offer of referral to an evidence-based stop smoking service has been made
- contra-indications and the potential for adverse effects
- the client's personal preferences
- the availability of appropriate counselling or support
- the likelihood that the client will follow the course of treatment
- their previous experience of smoking cessation aids.
See initial and ongoing support for more advice on smoking cessation for pregnant women.
Nicotine-assisted reduction to stop
Practitioners should provide NRT and appropriate support to individuals who want to follow the nicotine assisted reduction to stop (NARS) strategy only if it is part of a properly designed and conducted research study. Participants should include those who have repeatedly tried – and failed – to quit and those who are adamant that they do not want to quit abruptly.
Prescribing for young people
Offer young people aged 12-17 information, advice and support on how to stop smoking. Encourage use of local evidence-based stop smoking services by providing details on when, where and how to access them.
Use professional judgement to decide whether or not to offer NRT to young people over 12 years who show clear evidence of nicotine dependence. If NRT is prescribed, offer it as part of a supervised regime.
VareniclineThis recommendation is from Varenicline for smoking cessation. NICE technology appraisal guidance 123 (2007)
Varenicline is recommended within its licensed indications as an option for smokers who have expressed a desire to quit smoking.
Varenicline should normally be prescribed only as part of a programme of behavioural support.
See also 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-multipleBefore, during, after pregnancy
View the 'Smoking cessation in maternity services' pathPeople with a medical condition
Advice on quit smoking drugs for people who have cardiovascular or respiratory disease
Advice on quit smoking drugs for people who have cardiovascular or respiratory disease
Offer brief advice or, preferably, behavioural support from the local evidence-based stop smoking service and prescriptions of nicotine replacement therapy (NRT), varenicline or bupropion, according to clinical judgement.
See also NICE guidance on chronic obstructive pulmonary disease and evidence-based stop smoking services and quitlines in this pathway.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePrimary care
Primary care health practitioners (including community health workers)
Primary care health practitioners (including community health workers)
Offer advice to everyone who smokesThis recommendation is from Brief interventions and referral for smoking cessation (NICE public health guidance 1)
Everyone who smokes should be advised to quit, unless there are exceptional circumstancesOccasionally it might be inappropriate to advise a patient to quit. For example, because of their presenting condition or personal circumstances.. People who are not ready to quit should be asked to consider the possibility and encouraged to seek help in the future. If an individual who smokes presents with a smoking-related disease, the cessation advice may be linked to their medical condition.
Type of advice
People who smoke should be asked how interested they are in quitting. Advice to stop smoking should be sensitive to the individual's preferences, needs and circumstances: there is no evidence that the 'stages of change' modelDiClemente CC, Prochaska J et al. (1991) The process of smoking cessation: An analysis of precontemplation, contemplation and preparation stages of change. Journal of Consulting and Clinical Psychology. 59 (2): 295-304. is more effective than any other approach.
Actions for GPs
GPs should take the opportunity to advise all patients who smoke to quit when they attend a consultation. Those who want to stop should be offered a referral to an intensive support service (for example, an evidence-based stop smoking service). If they are unwilling or unable to accept this referral they should be offered pharmacotherapy and additional support. The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year, where possible.
Actions for nurses in primary and community care
Nurses in primary and community care should advise everyone who smokes to stop and refer them to an intensive support service (for example an evidence-based stop smoking service). If they are unwilling or unable to accept this referral, they should be offered pharmacotherapy by practitioners with suitable training and additional support.
Nurses who are trained stop smoking counsellors may 'refer' to themselves, where appropriate. The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year, where possible.
Monitoring
Monitoring systems should be set up to ensure health professionals have access to information on the current smoking status of their patients. This should include information on: a) the most recent occasion on which advice to stop was given, b) the nature of advice offered, and c) the response to that advice.
Training and referralThis is part of a recommendation from Smoking cessation services (NICE public health guidance 10)
Healthcare professionals should be trained to give brief advice on stopping tobacco use and should have contact with the local evidence-based stop smoking service to which they can refer people.
Patients referred for elective surgery should be encouraged to stop smoking before the operation. Patients who want to stop smoking for good should also be referred to the local evidence-based stop smoking service.
See also the recommendations for prescribing drugs to help people quit smoking, on helping adults who are disadvantaged to quit, evidence-based stop smoking services and quitlines, and recommendations on training in this pathway.
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-multiplePregnant women and mothers
View the 'Smoking cessation in maternity services' pathEverybody
Helping everybody to quit smoking
Helping everybody to quit smoking
Everyone who smokes should be advised to quit, unless there are exceptional circumstancesOccasionally it might be inappropriate to advise a patient to quit. For example, because of their presenting condition or personal circumstances.. People who are not ready to quit should be asked to consider the possibility and encouraged to seek help in the future. If an individual who smokes presents with a smoking-related disease, the cessation advice may be linked to their medical condition.
Type of advice
People who smoke should be asked how interested they are in quitting. Advice to stop smoking should be sensitive to the individual's preferences, needs and circumstances: there is no evidence that the 'stages of change' modelDiClemente CC, Prochaska J et al. (1991) The process of smoking cessation: An analysis of precontemplation, contemplation and preparation stages of change. Journal of Consulting and Clinical Psychology. 59 (2): 295-304. is more effective than any other approach.
Referring people for support
Health professionals, such as hospital clinicians, pharmacists and dentists, should refer people who smoke to an intensive support service (for example, an evidence-based stop smoking service). If the individual is unwilling or unable to accept this referral, practitioners with suitable training should offer a prescription of pharmacotherapy, see non-specialists who give advice, and additional support. Those who are trained stop smoking counsellors may 'refer' to themselves. The smoking status of those who are not ready to stop should be recorded in clinical records and reviewed with the individual once a year, where possible.
See also evidence-based stop smoking services and quitlines in this pathway.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeHospitals and long-term care
Hospitals and providers of long-term care
Hospitals and providers of long-term care
Smoking cessation 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.
Monitoring
Monitoring systems should be set up to ensure health professionals have access to information on the current smoking status of their patients. This should include information on: a) the most recent occasion on which advice to stop was given, b) the nature of advice offered, and c) the response to that advice.
Advice and interventionsThis is part of a recommendation from Smoking cessation services (NICE public health guidance 10)
Healthcare professionals should be trained to give brief advice on stopping tobacco use and should have contact with the local evidence-based stop smoking service to which they can refer people.
Healthcare professionals should identify and record the smoking and/or tobacco use status of all their patients. Those who use tobacco should be:
- reminded at every suitable opportunity of the health benefits of stopping
- offered brief advice and, if they want to stop using tobacco, referred to the local evidence-based stop smoking service. If patients do not wish to attend the service, they should be offered brief advice and support to help them quit, and pharmacotherapy as appropriate.
Patients referred for elective surgery should be encouraged to stop smoking before the operation. Patients who want to stop smoking for good should also be referred to the local evidence-based stop smoking service.
Hospital patients who use tobacco in any form should be offered advice and, if appropriate, NRT from a trained health professional or smoking cessation adviser while in hospital to help them to quit. They should also be offered an appointment with their local evidence-based stop smoking service. If they accept the offer, the appointment should be booked prior to their discharge. In exceptional circumstances it might be inappropriate to advise a patient to quit; for example, because of their presenting condition or personal situation.
Advice for people with cardiovascular or respiratory diseaseThis recommendation is from Smoking cessation services (NICE public health guidance 10)
Offer brief advice or, preferably, behavioural support from the local evidence-based stop smoking service and prescriptions of NRT, varenicline or bupropion, according to clinical judgement.
See also NICE guidance on chronic obstructive pulmonary disease and evidence-based stop smoking services and quitlines in this pathway.
Policy for long-term care
Develop a policy, using guidance provided by the Department of Health, to ensure that effective smoking cessation services are provided and promoted.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleCommunity health services
Community health services
Women of childbearing age
View the 'Smoking cessation in maternity services' pathEveryone who smokes
Advising everyone who smokes to quit and referring them for help where appropriate
Advising everyone who smokes to quit and referring them for help where appropriate
Advice
Everyone who smokes should be advised to quit, unless there are exceptional circumstancesOccasionally it might be inappropriate to advise a patient to quit. For example, because of their presenting condition or personal circumstances.. People who are not ready to quit should be asked to consider the possibility and encouraged to seek help in the future. If an individual who smokes presents with a smoking-related disease, the cessation advice may be linked to their medical condition.
Actions for nurses in primary and community care
Nurses in primary and community care should advise everyone who smokes to stop and refer them to an intensive support service (an evidence-based stop smoking service). If they are unwilling or unable to accept this referral, they should be offered pharmacotherapy by practitioners with suitable training – see non-specialists who give advice, and additional support in this pathway.
Nurses who are trained stop smoking counsellors may 'refer' to themselves, where appropriate. The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year, where possible.
Actions for community workers
Community workers should refer people who smoke to an intensive support service (for example, an evidence-based stop smoking service). Those who are trained stop smoking counsellors may 'refer' to themselves.
See also 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-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeAdults who are disadvantaged
Helping adults who are disadvantaged to quit smoking
Helping adults who are disadvantaged to quit smoking
Accessibility of servicesThis 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).
Service providers should monitor these methods and adjust them according to local needs.
Service providers should encourage everyone who is disadvantaged to register with a general practice.
For more information, see adults who are disadvantaged and 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-multipleMaternity services
View the 'Smoking cessation in maternity services' pathPaths 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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