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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.
Training recommendations
Recommendations for training
Stop-smoking services
Staff in evidenced-based stop-smoking services and quitline advisers
Staff in evidence-based stop-smoking services and quitline advisers
Evidence-based stop smoking services advisers and coordinators
Ensure training and continuing professional development is available for all those involved in providing stop smoking advice and support.
Ensure training complies with the Standard for training in smoking cessation treatments or its updates.
Telephone quitline services
Ensure publicly sponsored telephone quitlines offer a rapid, positive and authoritative response. Where possible, callers whose first language is not English should have access to information and support in their chosen language.
All staff should receive smoking cessation training (at least in brief interventions to help people stop smoking).
Staff who offer counselling should be trained to at least level two (individual behavioural counselling) and preferably they should hold an appropriate counselling qualification. Training should comply with the Standard for training in smoking cessation treatments or its updates.
See also the recommendations on training for people who do not work in specialist services in this pathway.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeNon-specialists who give advice
People who do not work in specialist stop-smoking services but who help prevent uptake or give advice on quitting smoking
People who do not work in specialist stop-smoking services but who help prevent uptake or give advice on quitting smoking
Education and training for healthcare professionalsThis recommendation is from Smoking cessation services (NICE public health guidance 10)
Who is the target group?
Doctors, nurses, midwives, pharmacists, dentists, and others who advise people on how to quit smoking.
Who should take action?
Those responsible for the education and training of healthcare workers and others who advise people how to quit smoking.
What action should they take?
Train all frontline healthcare staff to offer brief advice on smoking cessation in accordance with NICE guidance. Also train them to make referrals, where necessary and possible, to evidence-based stop smoking services.
Ensure training on how to support people to quit smoking is part of the core curriculum for healthcare undergraduates and postgraduates.
Train all evidence-based stop smoking services practitioners using a programme that complies with the standard for training in smoking cessation treatments or its updates.
Provide additional, specialised training for those working with specific groups, for example, people with mental health problems, those who are hospitalised and pregnant women who smoke.
Encourage and train healthcare professionals to ask patients or clients about all forms of tobacco use and to advise them of the dangers of exposure to secondhand smoke.
Training for healthcare staff working with women before, during and after pregnancyThis recommendation is from Quitting smoking in pregnancy and following childbirth (NICE public health guidance 26)
Ensure all midwives who deliver intensive stop-smoking interventions (one-to-one or group support – levels 2 and 3) are trained to the same standard as NHS stop-smoking advisers. The minimum standard for these interventions is set by the NHS Centre for Smoking Cessation and Training. They should also be provided with additional, specialised training and offered ongoing support and training updates NHS Centre for Smoking Cessation and Training.
Ensure all midwives who are not specialist stop-smoking advisers are trained to assess and record people's smoking status and their readiness to quit. They should also know about the health risks of smoking and the benefits of quitting – and understand why it can be difficult to stop. In addition, they should know about the treatments that can help people to quit and how to refer them to local services for treatment. (Acquisition of this knowledge and skill set is part of level 1 training in brief stop-smoking interventionsFor the national standard for level 1 see standard for training in smoking cessation treatments or future updates from the NHS Centre for Smoking Cessation and Training.. Please note, midwives are not advised to carry out brief interventions with pregnant women. However, they are advised to use these skills to initiate a referral to evidence-based stop smoking services.)
Ensure midwives and evidence-based stop-smoking specialist advisers who work with pregnant women:
- know how to ask them questions in such a way that encourages them to be open about their smoking
- always recommend quitting rather than cutting down
- have received accredited training in the use of CO monitors.
Ensure brief stop-smoking interventions (level 1) and intensive one-to-one and group support to stop smoking (levels 2 and 3) are incorporated into pre- and post-registration midwifery training and midwives' continuing professional development, as appropriate.
Ensure all healthcare and other professionals who work with the target group are trained in the same skills – and to the same standard – as those required of midwives who are not specialist smoking cessation advisers. This includes: GPs, practice nurses, health visitors, obstetricians, paediatricians, sonographers, midwives (including young people's lead midwives), family nurses and those working in fertility clinics, dental facilities and community pharmacies. It also includes those working in youth and teenage pregnancy services, children's centres, social services and voluntary and community organisations.
Ensure all the healthcare and other professionals listed in the previous bullet:
- know what support local evidence-based stop smoking services offer and how to refer the women being targeted
- understand the impact that smoking can have on a woman and her unborn child
- understand the dangers of exposing a pregnant woman and her unborn child – and other children – to secondhand smoke.
Ensure all training in relation to smoking and pregnancy addresses the:
- barriers that some professionals may feel they face when trying to tackle smoking with a pregnant woman (for example, they may feel that broaching the subject might damage their relationship)
- important role that partners and 'significant others' can play in helping a woman who smokes and is pregnant (or who has recently given birth) to quit. This includes the need to get them to consider quitting if they themselves smoke.
Implementation tools
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Teachers and support staff in schools
Teachers and support staff in schools
Provide training for all staff who will be involved in smoking prevention work.
Work in partnership to design, deliver, monitor and evaluate smoking prevention training and interventions. Partners could include: national and local education agencies, training agencies, local authorities, the school nursing service, voluntary sector organisations, local health improvement services and universities. See also behaviour change.
Source guidance
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Service providers who tackle health inequalities in the public, private, community and voluntary sectors
Service providers who tackle health inequalities in the public, private, community and voluntary sectors
Who should take action?
Commissioners and service providers (for example, community services, local authorities and others with a remit for tackling health inequalities).
What action should they take?
Ensure there are enough practitioners with the necessary skills to help people who are disadvantaged to adopt healthier lifestyles. For examples of the skills needed see recommendations for primary care and evidence-based stop smoking services and quitlines in this pathway, and the standard for training in smoking cessation treatments or updated versions of this.
Ensure practitioners have the skills to identify people who are disadvantaged and can develop services to meet their needs. For a set of generic principles to use when planning and delivering activities aimed at changing health-related behaviour see NICE guidance on behaviour change. For advice on getting communities involved see NICE guidance on community engagement.
Ensure service providers and practitioners have the ability to make services responsive to the needs of people who are disadvantaged. For example, they should be able to compare service provision with need, access, use and outcome using health equity audits. (For examples of the training and skills needed, refer to national organisations such as the Faculty of Public Health, British Psychological Society, Skills for Health and the Institute of Environmental Health.)
Implementation tools
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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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