A-Z
Topics
Latest

Smoking cessation in secondary care

About

What is covered

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

Updates

Updates to this NICE Pathway

12 December 2019 Lung cancer in adults (NICE quality standard 17) added.
6 August 2015 Smoking cessation: supporting people to stop smoking (NICE quality standard 43) added.
24 March 2015 Smoking: reducing tobacco use (NICE quality standard 82) added.

Person-centred care

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

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

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

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

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

Short Text

Everything NICE has said on helping people to stop smoking in secondary care in an interactive flowchart

What is covered

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

Updates

Updates to this NICE Pathway

12 December 2019 Lung cancer in adults (NICE quality standard 17) added.
6 August 2015 Smoking cessation: supporting people to stop smoking (NICE quality standard 43) added.
24 March 2015 Smoking: reducing tobacco use (NICE quality standard 82) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Varenicline for smoking cessation (2007) NICE technology appraisal guidance 123
Smoking: reducing and preventing tobacco use (2015) NICE quality standard 82
Smoking: supporting people to stop (2013) NICE quality standard 43
Lung cancer in adults (2012 updated 2019) NICE quality standard 17

Quality standards

Smoking: supporting people to stop

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

Lung cancer in adults

These quality statements are taken from the lung cancer in adults quality standard. The quality standard defines clinical best practice for lung cancer in adults and should be read in full.

Quality statements

Identifying people who smoke

This quality statement is taken from the smoking: supporting people to stop quality standard. The quality standard defines clinical best practice for smoking: supporting people to stop and should be read in full.

Quality statement

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

Rationale

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

Quality measures

Structure
Evidence of local arrangements to ensure that people are asked if they smoke by their healthcare practitioner, and those who smoke are offered advice on how to stop.
Data source: Local data collection.
Process
a) Proportion of people who are asked if they smoke by their healthcare practitioner.
Numerator – the number of people in the denominator who are asked if they smoke by their healthcare practitioner.
Denominator – the number of people who have face-to-face contact with a healthcare practitioner.
Data source: a) Local data collection and the quality and outcomes framework (QOF) indicator SMOK001.
b) Proportion of people who smoke who receive advice on how to stop.
Numerator – the number of people in the denominator who receive advice on how to stop.
Denominator – the number of people who report that they smoke during face-to-face contact with a healthcare practitioner.
Data source: b) Local data collection and the QOF indicator SMOK004.

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

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

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

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

Source guidance

Definition of terms used in this quality statement

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

Equality and diversity considerations

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

Referral to smoking cessation services

This quality statement is taken from the smoking: supporting people to stop quality standard. The quality standard defines clinical best practice for smoking: supporting people to stop and should be read in full.

Quality statement

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

Rationale

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

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke are offered a referral to an evidence-based smoking cessation service.
Data source: Local data collection.
Process
Proportion of people who smoke who are referred to an evidence-based smoking cessation service.
Numerator – the number of people in the denominator who are referred to an evidence-based smoking cessation service.
Denominator – the number of people identified as smokers in any healthcare setting.
Data source: Local data collection and the quality and outcomes framework (QOF) indicator SMOK004.

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

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

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

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

Source guidance

Definitions of terms used in this quality statement

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

Equality and diversity considerations

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

Behavioural support with pharmacotherapy

This quality statement is taken from the smoking: supporting people to stop quality standard. The quality standard defines clinical best practice for smoking: supporting people to stop and should be read in full.

Quality statement

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

Rationale

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

Quality measures

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

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

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

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

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

Source guidance

Definitions of terms used in this quality statement

Behavioural support
This can be individual or group behavioural support.
NICE’s guideline on stop smoking interventions and services states that individual behavioural support involves scheduled face to face meetings between someone who smokes and a counsellor trained in smoking cessation. Typically, it involves weekly sessions over a period of at least 4 weeks after the quit date and is normally combined with pharmacotherapy.
It also states that group behavioural support involves scheduled meetings in which people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy). This therapy is offered weekly for at least the first 4 weeks of a quit attempt (that is, for 4 weeks following the quit date). It is normally combined with pharmacotherapy.
Pharmacotherapy
Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion.
NICE’s guideline on stopping smoking in pregnancy and after childbirth states that there should be a discussion about the risks and benefits of NRT with pregnant women who smoke. Nicotine replacement therapy should be offered if smoking cessation without NRT fails, or practitioner judgement should be used if women express a clear preference for NRT. Neither varenicline nor bupropion should be offered to pregnant or breastfeeding women.
A summary of further considerations relating to pharmacotherapy is provided in quality statement 4.
Evidence-based stop smoking services
These are local services providing accessible, evidence based and cost effective support to people who want to stop smoking.

Pharmacotherapy

This quality statement is taken from the smoking: supporting people to stop quality standard. The quality standard defines clinical best practice for smoking: supporting people to stop and should be read in full.

Quality statement

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

Rationale

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

Quality measures

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

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

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

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

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

Source guidance

Definitions of terms used in this quality statement

Pharmacotherapy
Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion.
It is important that people who smoke who receive pharmacotherapy receive a full course, which will vary depending on the individual smoker. A full course for NRT is at least 8 weeks, for varenicline it is at least 12 weeks and for bupropion it is at least 8 weeks.
NICE’s technology appraisal guidance on varenicline for smoking cessation states that varenicline should normally be prescribed only as part of a programme of behavioural support.
NICE’s guideline on stopping smoking in pregnancy and after childbirth states that there should be a discussion about the risks and benefits of NRT with pregnant women who smoke. Nicotine replacement therapy should be offered if smoking cessation without NRT fails, or practitioner judgement should be used if women express a clear preference for NRT. Neither varenicline nor bupropion should be offered to pregnant or breastfeeding women.

Equality and diversity considerations

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

Outcome measurement

This quality statement is taken from the smoking: supporting people to stop quality standard. The quality standard defines clinical best practice for smoking: supporting people to stop and should be read in full.

Quality statement

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

Rationale

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

Quality measures

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

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

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

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

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

Source guidance

Definition of terms used in this quality statement

NICE’s guideline on stop smoking interventions and services states that success should be defined by a carbon monoxide monitor reading of less than 10 ppm at 4 weeks after the quit date. This does not imply that treatment should stop at 4 weeks.
Evidence-based smoking cessation services
These are local services providing accessible, evidence based and cost effective support to people who want to stop smoking.

Schools and colleges: interventions

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

Quality statement

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

Rationale

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

Quality measures

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

What the quality statement means for schools and colleges

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

What the quality statement means for children and young people

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

Source guidance

Smoking prevention in schools (2010) NICE guideline PH23, recommendations 2 and 3

Definitions of terms used in this quality statement

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

Equality and diversity considerations

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

Schools and colleges: smokefree grounds

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

Quality statement

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

Rationale

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

Quality measures

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

What the quality statement means for schools and colleges

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

What the quality statement means for children and young people

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

Source guidance

Smoking prevention in schools (2010) NICE guideline PH23, recommendation 1

Definitions of terms used in this quality statement

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

Equality and diversity considerations

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

Underage sales

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

Quality statement

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

Rationale

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

Quality measures

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

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

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

What the quality statement means for children and young people

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

Source guidance

Smoking: preventing uptake in children and young people (2008, updated 2014) NICE guideline PH14, recommendation 5

Definitions of terms used in this quality statement

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

Equality and diversity considerations

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

Workplace policy

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

Quality statement

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

Rationale

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

Quality measures

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

What the quality statement means for commissioners

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

What the quality statement means for employers and employees

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

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

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

Source guidance

Smoking: workplace interventions (2007) NICE guideline PH5, recommendations 1 and 5

Equality and diversity considerations

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

Healthcare services: employee contracts

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

Quality statement

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

Rationale

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

Quality measures

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

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

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

What the quality statement means for patients and visitors

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

Source guidance

Definitions of terms used in this quality statement

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

Healthcare settings: smokefree grounds

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

Quality statement

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

Rationale

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

Quality measures

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

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

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

What the quality statement means for patients and visitors

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

Source guidance

Definitions of terms used in this quality statement

Healthcare settings
All publicly funded community, primary, secondary and tertiary healthcare facilities, including buildings, grounds and vehicles.
[Adapted from NICE guideline PH48]

Equality and diversity considerations

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

Healthcare settings: nicotine-containing products and stop smoking pharmacotherapies

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

Quality statement

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

Rationale

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

Quality measures

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

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

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

What the quality statement means for patients and visitors

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

Source guidance

Smoking: acute, maternity and mental health services (2013) NICE guideline PH48, recommendations 8 and 11

Definitions of terms used in this quality statement

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

Equality and diversity considerations

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

Media campaigns

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

Quality statement

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

Rationale

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

Quality measures

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

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

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

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

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

Source guidance

Definitions of terms used in this quality statement

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

Equality and diversity considerations

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

Illicit tobacco: placeholder statement

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

Quality statement

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

What is a placeholder statement?

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

What is illicit tobacco?

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

Rationale

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

Public awareness

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

Quality statement

Local authorities and healthcare commissioning groups use coordinated campaigns to raise awareness of the symptoms and signs of lung cancer and encourage people to seek medical advice if they need to.

Rationale

Diagnosing lung cancer at a late stage is associated with poor health outcomes, including shorter survival. Raising awareness of the symptoms and signs of lung cancer can encourage earlier presentation and diagnosis, including among people who have never smoked. Locally coordinated awareness campaigns can engage groups at risk in the local population. Earlier diagnosis will increase the number of adults with lung cancer able to have treatment with curative intent.

Quality measures

Structure
a) Evidence of local needs assessment to identify population groups for campaigns to raise awareness of the symptoms and signs of lung cancer and encourage people to seek medical advice if they need to.
Data source: Local data collection, for example, joint strategic needs assessment.
b) Evidence of locally coordinated campaigns to raise awareness of the symptoms and signs of lung cancer and encourage people to seek medical advice if they need to.
Data source: Local data collection, for example, campaign plans or materials such as posters, leaflets and social media messaging.
c) Evidence of evaluation of locally coordinated campaigns to raise awareness of the symptoms and signs of lung cancer and encourage people to seek medical advice if they need to.
Data source: Local data collection, for example, evaluation reports.
Outcome
a) Proportion of adults in the population who can recognise and recall the symptoms and signs of lung cancer.
Numerator – the number in the denominator who can recognise and recall the symptoms and signs of lung cancer.
Denominator – the number of adults in the population.
Data source: Local data collection, for example, a sample survey based on Cancer Research UK’s Cancer Awareness Measure.
b) Proportion of adults with a new diagnosis of lung cancer who were diagnosed via an emergency route.
Numerator – the number in the denominator who were diagnosed via an emergency route.
Denominator – the number of adults with a new diagnosis of lung cancer.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset collects data on the source of referral.
c) Proportion of adults with a new diagnosis of lung cancer diagnosed at stage I or II.
Numerator – the number in the denominator diagnosed at stage I or II.
Denominator – the number of adults with a new diagnosis of lung cancer.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.

What the quality statement means for different audiences

Local authorities and healthcare commissioning groups work together to develop and implement campaigns, tailored to the needs of the local population, to raise awareness of the symptoms and signs of lung cancer and encourage people to seek medical advice if they need to. They may also promote national lung cancer awareness campaigns locally. Local authorities and healthcare commissioning groups evaluate the impact of local campaigns, including the level of engagement with high-risk groups.
Health and social care practitioners (such as GPs, practice nurses, district nurses, community pharmacists and social care practitioners) get involved in local campaigns to raise awareness of the symptoms and signs of lung cancer and encourage people to seek medical advice if they need to.
People know about the symptoms and signs of lung cancer and are encouraged to get medical advice if they are worried about any symptoms. People know that getting advice quickly means that any cancer is more likely to be treated successfully.

Source guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendation 1.1.1

Definitions of terms used in this quality statement

Symptoms and signs of lung cancer
Symptoms and signs of lung cancer that should be investigated include:
  • 2 or more of the following unexplained symptoms in people aged 40 years and over, or 1 or more in people aged 40 years or over who have ever smoked:
    • cough
    • fatigue
    • shortness of breath
    • chest pain
    • weight loss
    • appetite loss
  • any of the following in people aged 40 years and over:
    • unexplained haemoptysis
    • persistent or recurrent chest infection
    • finger clubbing
    • supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
    • chest signs consistent with lung cancer
    • thrombocytosis.
[NICE’s guideline on suspected cancer: recognition and referral, recommendations 1.1.1, 1.1.2 and 1.1.3]

Equality and diversity considerations

Local authorities and healthcare commissioning groups should ensure that awareness campaigns include approaches that engage people living in socioeconomically deprived areas. Awareness campaigns should also be accessible to people who do not speak or read English.

Stopping smoking

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

Quality statement

Adults with suspected or confirmed lung cancer who smoke receive evidence-based stop smoking support.

Rationale

People with suspected or confirmed lung cancer who smoke should be encouraged to stop smoking to reduce the risk of treatment-related complications and other smoking-related conditions and increase their life expectancy. They should be provided with evidence-based support to help them to stop smoking.

Quality measures

Structure
a) Evidence of local arrangements to ensure that adults with suspected or confirmed lung cancer who smoke are given advice about why it is important to stop smoking.
Data source: Local data collection, for example, service protocols.
b) Evidence of local arrangements to provide evidence-based support for adults with suspected or confirmed lung cancer to help them to stop smoking.
Data source: Local data collection, for example, service specification and protocols.
Process
Proportion of adults with suspected or confirmed lung cancer who smoke who receive evidence-based support to stop smoking.
Numerator – the number in the denominator who receive evidence-based support to stop smoking.
Denominator – the number of adults with suspected or confirmed lung cancer who smoke.
Data source: Royal College of Physicians National Lung Cancer Audit (measure in development). Data on smoking status and whether treatment for tobacco addiction was given from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.
Outcome
a) Smoking rates in adults with lung cancer having treatment with curative intent.
Data source: Local data collection, for example, audit of patient records.
b) 1-year survival rate for adults with lung cancer treated with curative intent.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.

What the quality statement means for different audiences

Service providers (such as primary care, community services, secondary and tertiary care) ensure that processes are in place to provide advice to adults with suspected or confirmed lung cancer who smoke about why it is important to stop smoking. Providers ensure that they can provide evidence-based support to help people with suspected or confirmed lung cancer to stop smoking. This may also include referral pathways to evidence-based stop smoking support.
Healthcare professionals (such as GPs, pharmacists, clinical nurse specialists, consultants and radiographers) provide advice to adults with suspected or confirmed lung cancer who smoke about why it is important to stop smoking. They arrange for them to access evidence-based stop smoking support if they want to stop.
Commissioners (such as clinical commissioning groups, NHS England and local authorities) ensure that they commission services which provide evidence-based stop smoking support to adults with suspected or confirmed lung cancer who smoke.
Adults with suspected or confirmed lung cancer who smoke are told that it is important to stop smoking to avoid complications during treatment and prevent other smoking-related illnesses. They are told that stopping smoking may improve how long they live, and they are given help if they want to give up.

Source guidance

Definitions of terms used in this quality statement

Suspected lung cancer
Adults with symptoms and signs of lung cancer who are referred for investigation.
[Expert opinion]
Evidence-based stop smoking support
The following interventions should be available:
  • behavioural support (individual and group)
  • bupropion (see information on bupropion hydrochloride in the British national formulary)
  • nicotine replacement therapy – short and long acting
  • varenicline (see information on varenicline in the British national formulary)
  • very brief advice.
[NICE’s guideline on stop smoking interventions and services, recommendation 1.3.1 and terms used in this guideline and NICE’s guideline on lung cancer, recommendation 1.4.3]

Equality and diversity considerations

Information about stopping smoking should be in a format that suits the person’s needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate. People should have access to an interpreter or advocate if needed. For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Lung cancer clinical nurse specialist

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

Quality statement

Adults with suspected or confirmed lung cancer have access to a named lung cancer clinical nurse specialist.

Rationale

Lung cancer clinical nurse specialists can provide specialist guidance and support at all stages of care and treatment for adults with lung cancer and their family and carers. They can act as the key worker, coordinating care between secondary and primary care and providing continuity. Having a named clinical nurse specialist will ensure that adults with lung cancer can access advice and support whenever they need it, helping to improve their quality of life and health outcomes.

Quality measures

Structure
a) Evidence of the availability of clinical nurse specialists who specialise in the care and support of adults with lung cancer.
Data source: Local data collection, for example, workforce plans or staff rotas. Clinical advice to cancer alliances for the commissioning of the whole lung cancer pathway (Lung Cancer Clinical Expert Group, 2017) recommends 1 whole-time equivalent nurse for an annual caseload of 80 new patients.
b) Evidence of local arrangements to ensure that adults with lung cancer know how to contact the lung cancer clinical nurse specialist between hospital visits.
Data source: Local data collection, for example, service protocols and information on how to contact a clinical nurse specialist.
Process
a) Proportion of adults with lung cancer who had a lung cancer clinical nurse specialist present at diagnosis.
Numerator – the number in the denominator who had a lung cancer clinical nurse specialist present at diagnosis.
Denominator – the number of adults with lung cancer.
Data source: Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on people who had a lung cancer clinical nurse specialist present for diagnosis.
b) Proportion of adults with lung cancer who have had assessment by a lung cancer clinical nurse specialist.
Numerator – the number in the denominator who have had assessment by a lung cancer clinical nurse specialist.
Denominator – the number of adults with lung cancer.
Data source: Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on people assessed by a lung cancer clinical nurse specialist.
c) Proportion of adults with lung cancer who were given the name of a lung cancer clinical nurse specialist who would support them.
Numerator – the number in the denominator who were given the name of a lung cancer clinical nurse specialist who would support them.
Denominator – the number of adults with lung cancer.
Data source: Local data collection, for example, audit of patient records. Quality Health National Cancer Patient Experience Survey includes data on people with lung cancer who were given the name of a clinical nurse specialist who would support them through their treatment.
Outcome
a) Proportion of adults with lung cancer who are satisfied with the support provided by a lung cancer clinical nurse specialist.
Numerator – the number in the denominator who are satisfied with the support provided by a lung cancer clinical nurse specialist.
Denominator – the number of adults with lung cancer.
Data source: Local data collection, for example, a survey of adults with lung cancer. Quality Health National Cancer Patient Experience Survey includes data on ease of contacting a clinical nurse specialist for people with lung cancer receiving hospital treatment.
b) Health-related quality of life for adults with lung cancer.
Data source: Local data collection, for example, a survey of adults with lung cancer or their families and carers including patient-reported outcome measure.

What the quality statement means for different audiences

Service providers (such as secondary and tertiary care) ensure that lung cancer clinical nurse specialists are available to support adults with suspected or confirmed lung cancer throughout their care. Providers ensure that processes are in place for adults with lung cancer to be supported by a lung cancer clinical nurse specialist at diagnosis and for them to have regular assessments with a lung cancer clinical nurse specialist at key points in their care.
Healthcare professionals (such as members of the lung cancer multidisciplinary team) ensure that adults with suspected or confirmed lung cancer know how to contact a lung cancer clinical nurse specialist between hospital visits. Healthcare professionals share information with the lung cancer clinical nurse specialist to allow them to coordinate care for adults with lung cancer. Lung cancer clinical nurse specialists provide support and information to adults with lung cancer and carry out assessments at key points of care.
Commissioners (clinical commissioning groups) commission services with enough clinical nurse specialists with expertise in lung cancer to support all adults with lung cancer throughout all stages of care.
Adults with lung cancer can contact a clinical nurse specialist (a nurse experienced in treating lung cancer) for information, advice and support throughout their care.

Source guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendations 1.2.2, 1.3.33 and 1.6.3.

Definitions of terms used in this quality statement

Suspected lung cancer
Adults with symptoms and signs of lung cancer who are referred for investigation.
[Expert opinion]
Lung cancer clinical nurse specialist
This can include surgical or oncology lung cancer clinical nurse specialists as well as palliative care clinical nurse specialists, depending on the stage of care.
[Expert opinion]

Equality and diversity considerations

Lung cancer clinical nurse specialists should ensure that people are provided with information that they can easily read and understand themselves, or with support, so that they can communicate effectively with health and care services. Information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate. People should have access to an interpreter or advocate if needed. For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Investigations

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

Quality statement

Adults with lung cancer being considered for treatment with curative intent have investigations to accurately determine diagnosis and stage, and to assess lung function.

Rationale

Undergoing treatment with curative intent when lung cancer has already spread can reduce quality of life without increasing life expectancy. It is important that adults who are being considered for treatment with curative intent have accurate diagnosis and staging. This will ensure that the most appropriate treatment is provided. Risk assessment for people being considered for treatment with curative intent should include assessment of lung function because this is a good predictor of treatment outcomes.

Quality measures

Structure
a) Evidence of local processes to record investigations to accurately determine diagnosis and stage and to assess lung function, for adults with lung cancer who are being considered for treatment with curative intent.
Data source: Local data collection, for example, local protocols.
b) Evidence of availability of positron-emission tomography CT (PET-CT) for adults with lung cancer who are being considered for treatment with curative intent.
Data source: Local data collection, for example, waiting times for PET-CT (including results) for adults with lung cancer. NHS England’s Implementing a timed lung cancer diagnostic pathway indicates that investigations should be complete by day 14 in the 28-day pathway.
c) Evidence of availability of brain imaging for adults with non-small-cell lung cancer stage II or III who are being considered for treatment with curative intent.
Data source: Local data collection, for example, access to MRI and waiting times for brain imaging (including results) for adults with non-small-cell lung cancer. NHS England’s Implementing a timed lung cancer diagnostic pathway indicates that investigations should be complete by day 14 in the 28-day pathway.
Process
a) Proportion of adults with lung cancer treated with curative intent who had PET-CT before starting treatment.
Numerator – the number in the denominator who had PET-CT before starting treatment.
Denominator – the number of adults with lung cancer treated with curative intent.
Data source: Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on people receiving a PET-CT scan before surgery or radical radiotherapy.
b) Proportion of adults with non-small-cell lung cancer stage II or III treated with curative intent who had brain imaging before starting treatment.
Numerator – the number in the denominator who had brain imaging before starting treatment.
Denominator – the number of adults with non-small-cell lung cancer stage II or III treated with curative intent.
Data source: Local data collection, for example, audit of patient records.
c) Proportion of adults with non-small-cell lung cancer treated with curative intent who had spirometry and transfer factor (TLCO) before starting treatment.
Numerator – the number in the denominator who had spirometry and TLCO before starting treatment.
Denominator – the number of adults with non-small-cell lung cancer treated with curative intent.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset includes data on diffusion capacity or TLCO, and forced expiratory volume (FEV1). Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on completeness for FEV1 and FEV1% predicted for people with stage I or II lung cancer and performance status 0 to 1.
d) Proportion of adults with lung cancer who had clinical stage and performance status recorded.
Numerator – the number in the denominator who had clinical stage and performance status recorded.
Denominator – the number of adults with lung cancer.
Data source: Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on valid performance status and stage.
Outcome
1-year survival rate for adults with lung cancer treated with curative intent.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.

What the quality statement means for different audiences

Service providers (such as secondary and tertiary care) ensure that processes are in place for adults with lung cancer who are being considered for treatment with curative intent to have investigations to accurately determine diagnosis and stage, and to check lung function. Providers ensure that adults with lung cancer do not start treatment with curative intent until the results of PET-CT, brain imaging and lung function (if relevant) are available. Providers follow the NHS England lung cancer diagnostic pathway to ensure investigations are timely and do not lead to treatment being delayed.
Healthcare professionals (such as consultants, clinical nurse specialists and consultant radiographers) arrange for adults with lung cancer who are being considered for treatment with curative intent to have investigations to accurately determine diagnosis and stage, and to check lung function. Healthcare professionals give people information about the purpose of the investigations, and discuss the results with them, including what they might mean for their treatment.
Commissioners (such as clinical commissioning groups) commission services that ensure adults with lung cancer who are being considered for treatment with curative intent have investigations to accurately determine diagnosis and stage, and to check lung function. Commissioners ensure that providers have the equipment and capacity to carry out PET-CT and brain imaging without delaying the start of treatment with curative intent.
Adults with lung cancer who may be able to have treatment to cure their cancer have scans to confirm the diagnosis and stage of the cancer, and tests to check how well their lungs are working. The results will help to identify the most suitable treatment.

Source guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendations 1.3.4, 1.3.18, 1.3.19, 1.3.22, 1.3.23, 1.3.24, 1.3.25 and 1.4.13.

Definitions of terms used in this quality statement

Investigations to accurately determine diagnosis and stage, and to assess lung function
Investigations should include:
  • PET-CT
  • stage-specific brain imaging for people with non-small-cell lung cancer
    • no brain imaging for people with stage I
    • contrast-enhanced brain CT for people with stage II
    • contrast-enhanced brain MRI for people with stage III
  • spirometry and TLCO for people with non-small-cell lung cancer
[NICE’s guideline on lung cancer, recommendations 1.3.4, 1.3.23, 1.3.24, 1.3.25 and 1.4.13]
Treatment with curative intent for lung cancer
There are a variety of treatment options and combinations of treatment that aim to remove the tumour and effect a cure for adults with lung cancer. These include: surgery, radiotherapy, chemotherapy and chemoradiotherapy. The approach to treatment will depend on the type of lung cancer, the clinical stage of the tumour, the person’s performance status, comorbidities and the person’s choice.
[NICE’s guideline on lung cancer and expert opinion]

Treatment with curative intent

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

Quality statement

Adults with non-small-cell lung cancer stage I or II and good performance status have treatment with curative intent.

Rationale

Treatment with curative intent improves survival. There are a variety of options for treatment with curative intent in adults with stage I or II non-small-cell lung cancer who are well enough. Decisions about these treatment options should be taken at multidisciplinary team meetings that include all specialist core members. Adults with lung cancer should be involved in deciding which treatment or combinations of treatment best suit them.

Quality measures

Structure
a) Evidence that lung cancer multidisciplinary team meetings include all specialist core members.
Data source: Local data collection, such as attendance monitoring for lung cancer multidisciplinary team meetings.
b) Evidence of local processes for discussing options for treatment with curative intent with adults with stage I or II non-small-cell lung cancer and good performance status.
Data source: Local data collection, such as local clinical protocols and patient information resources.
c) Evidence of local arrangements and written clinical protocols to ensure that adults with non-small-cell lung cancer stage I or II and good performance status have treatment with curative intent.
Data source: Local data collection, such as local clinical protocols.
Process
Proportion of adults with non-small-cell lung cancer stage I or II and good performance status who have treatment with curative intent.
Numerator – the number in the denominator who have treatment with curative intent.
Denominator – the number of adults with non-small-cell lung cancer stage I or II and good performance status.
Data source: Royal College of Physicians National Lung Cancer Audit uses data from National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset on people with non-small-cell lung cancer stage I or II and performance status 0 to 2 receiving treatment with curative intent.
Outcome
a) Proportion of adults with non-small-cell lung cancer stage I or II and good performance status who are satisfied that treatment options were explained to them.
Numerator – the number in the denominator who are satisfied that treatment options were explained to them.
Denominator – the number of adults with non-small-cell lung cancer stage I or II and good performance status.
Data source: Local data collection, for example, a survey of adults with non-small-cell lung cancer or their families and carers.
b) 1-year survival rate for adults with non-small-cell lung cancer stage I or II.
Data source National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.
c) 5-year survival rate for adults with non-small-cell lung cancer stage I or II.
Data source: Local data collection, for example, audit of patient review records.

What the quality statement means for different audiences

Service providers (such as secondary and tertiary care) ensure that lung cancer multidisciplinary team meetings include all specialist core members to support decisions on treatment for adults with lung cancer. Service providers ensure that staff are trained to discuss the risks and benefits of treatment options with adults with stage I or II non-small-cell lung cancer and good performance status and to support shared decision making. Service providers ensure that all treatment options are available.
Healthcare professionals (such as members of lung cancer multidisciplinary teams) attend lung cancer multidisciplinary team meetings and advise on treatment options for adults with non-small-cell lung cancer. Healthcare professionals discuss the risks and benefits of treatment options with adults with stage I or II non-small-cell lung cancer and good performance status and support them to make decisions about treatment.
Commissioners (such as clinical commissioning groups) commission services that ensure that adults with non-small-cell lung cancer stage I or II and good performance status can receive treatment with curative intent. Commissioners ensure that services have expertise to support decisions about optimal treatment for adults with non-small-cell lung cancer and that all suitable treatment options are available.
Adults who are fit and have early-stage non-small-cell lung cancer are offered treatment that may cure their cancer. They discuss treatment options with a healthcare professional who explains the risks and benefits of the different options.

Source guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendations 1.4.20, 1.4.21, 1.4.24, 1.4.27, 1.4.34 and 1.4.35

Definitions of terms used in this quality statement

Treatment with curative intent for non-small-cell lung cancer
There are a variety of options for treatment with curative intent for adults with stage I or II non-small-cell lung cancer and good performance status. The approach to treatment will depend on the clinical stage of the tumour, the person’s performance status, comorbidities and personal choice. The following options should be available, and the risks and benefits of the options that are suitable should be discussed with the person:
  • surgery – lobectomy, sublobar resection, bronchoangioplastic surgery, bilobectomy or pneumonectomy
  • radiotherapy – stereotactic ablative radiotherapy (SABR) or conventional or hyperfractionated radiotherapy
  • chemoradiotherapy
  • multimodality treatment (surgery, radiotherapy and chemotherapy in any combination)
[NICE’s guideline on lung cancer, recommendations 1.4.20, 1.4.21, 1.4.24, 1.4.27, 1.4.32, 1.4.33, 1.4.34 and 1.4.35]
Good performance status
A measure of how well a patient can perform ordinary tasks and carry out daily activities. A good performance status in this context is defined as a World Health Organization (WHO) score of 0 to 2:
  • 0, able to carry out all normal activity without restriction
  • 1, restricted in strenuous activity but ambulatory and able to carry out light work
  • 2, ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours.
[NICE’s 2011 full guideline on lung cancer, glossary (appendix 6) and Royal College of Physicians National Lung Cancer Audit]

Equality and diversity considerations

Healthcare professionals should ensure that people with non-small-cell lung cancer are not excluded from treatment with curative intent because of their age. They should support older people to consider all the treatment options carefully before deciding which option suits them best.

Tissue sampling

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

Quality statement

Adults with non-small-cell lung cancer stage III or IV who are having tissue sampling, have samples taken that are suitable for pathological diagnosis and assessment of predictive biomarkers.

Rationale

Drug treatments for non-small-cell lung cancer work best if they are targeted according to the histological sub-type and predictive biomarkers of the tumour. Obtaining a pathological diagnosis and assessment of predictive biomarkers for a lung tumour in people with good performance status ensures that the most appropriate treatment regimen is offered. It is important that samples taken for diagnosis and staging yield enough material for pathology tests and immunohistochemical and/or genetic analysis. This will reduce delays to treatment by minimising the need for further sampling before making treatment decisions.

Quality measures

Structure
a) Evidence of the availability of radiologists and respiratory specialists experienced in performing lung biopsies for adults with lung cancer.
Data source: Local data collection, for example, workforce plans or staff rotas.
b) Evidence of local processes to ensure that adults with non-small-cell lung cancer stage III or IV who are having tissue sampling, have samples taken that are suitable for pathological diagnosis and assessment of predictive biomarkers.
Data source: Local data collection, for example, service protocols.
c) Evidence of audit of the local test performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for people with lung cancer.
Data source: Local data collection, for example, audit reports. Specific details of audit for EBUS-TBNA are included in the British Thoracic Society quality standards for diagnostic flexible bronchoscopy in adults (statements 5a and b).
Process
a) Proportion of adults with non-small-cell lung cancer stage III or IV who have a second diagnostic test in order to determine histological sub-type or predictive biomarkers.
Numerator – the number in the denominator who have a second diagnostic test in order to determine histological sub-type or predictive biomarkers.
Denominator – the number of adults with non-small-cell lung cancer stage III or IV.
Data source: Local data collection, for example, audit of patient records. For measurement purposes, this measure aims to identify where suitable samples have not been taken, making it necessary for a second test to be carried out.
b) Proportion of adults with non-small-cell lung cancer stage III or IV for whom the reported tumour sub-type is ‘not otherwise specified’.
Numerator – the number in the denominator for whom the reported tumour sub-type is ‘not otherwise specified’.
Denominator – the number of adults with non-small-cell lung cancer stage III or IV.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset. For measurement purposes, this measure aims to identify where suitable samples have not been taken, resulting in a sub-type ‘not otherwise specified’.
c) Proportion of adults with non-small-cell lung cancer stage III or IV and performance status 0 to 2 who are successfully tested for all relevant biomarkers.
Numerator – the number in the denominator who are successfully tested for all relevant biomarkers.
Denominator – the number of adults with non-small-cell lung cancer stage III or IV and performance status 0 to 2.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset includes data on epidermal growth factor receptor mutational status, ALK fusion status, ROS1 Fusion status and PD-L1 expression.
Outcome
a) Proportion of adults with non-small-cell lung cancer stage III or IV and performance status 0 to 2 who have a pathological diagnosis.
Numerator – the number in the denominator who have a pathological diagnosis.
Denominator – the number of adults with non-small-cell lung cancer stage III or IV and performance status 0 to 2.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.
b) 1-year survival rate for adults with non-small-cell lung cancer stage III or IV.
Data source: National Cancer Registration and Analysis Service Cancer Outcomes and Services Dataset.

What the quality statement means for different audiences

Service providers (such as secondary and tertiary care) ensure that adults with non-small-cell lung cancer stage III or IV who are having tissue sampling, have samples taken that are suitable for pathological diagnosis and assessment of predictive biomarkers. Providers ensure that lung cancer multidisciplinary teams include radiologists and respiratory specialists experienced in performing lung biopsies for adults with lung cancer. Providers also audit local test performance for EBUS-TBNA and EUS-FNA to assess the sensitivity of the procedures and the suitability of samples.
Healthcare professionals (such as respiratory specialists and radiologists) take tissue samples from adults with non-small-cell lung cancer stage III or IV that are suitable for pathological diagnosis and assessment of predictive biomarkers.
Commissioners (such as clinical commissioning groups) commission services that ensure that adults with non-small-cell lung cancer stage III or IV have tissue samples taken that are suitable for pathological diagnosis and assessment of predictive biomarkers.
Adults with advanced non-small-cell lung cancer have tissue samples taken that give enough information for a complete diagnosis and to guide treatment options.

Source guidance

Lung cancer: diagnosis and management (2019) NICE guideline NG122, recommendation 1.3.11

Definitions of terms used in this quality statement

Samples suitable for pathological diagnosis and assessment of predictive biomarkers
Providing there is no risk to the person, tissue samples of sufficient size and quality should be taken to support pathological diagnosis, including tumour sub-typing and assessment of predictive biomarkers. The samples should:
  • allow pathologists to classify non-small-cell lung cancer into squamous cell carcinoma or adenocarcinoma wherever possible
  • support stage-appropriate immunohistochemical and/or genetic analysis to detect specific biomarkers that predict whether targeted treatments are likely to be effective, for example, epidermal growth factor receptor (EGFR) mutations, anaplastic lymphoma kinase (ALK) gene rearrangement, programmed death-ligand 1 (PD-L1) expression or ROS-1 gene mutation.
[NICE’s 2011 full guideline on lung cancer and expert opinion]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

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

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

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

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

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

Supporting information

Intensive interventions typically involve scheduled face-to-face meetings between someone who smokes, either alone or in a group, and a counsellor trained to provide stop smoking support. The discussions may include information, practical advice about goal-setting, self-monitoring and dealing with the barriers to stopping smoking as well as encouragement. Intensive behavioural support also includes anticipating and dealing with the challenges of stopping. Established and effective behaviour-change techniques should be used (see NICE public health guidance on Behaviour change). Support is typically offered weekly for at least the first 4 weeks of a quit attempt (that is, for 4 weeks after the quit date) or 4 weeks after discharge from hospital (where a quit attempt may have started before discharge), and normally given with stop smoking pharmacotherapy.
Nicotine-containing products that are licensed have been given marketing authorisation by the Medicines and Healthcare products Regulatory Agency (MHRA). At the time of publication (November 2013), nicotine replacement therapy (NRT) products were the only type of licensed nicotine-containing product. However, the MHRA has decided that all nicotine-containing products should be regulated and this is expected to come into effect in 2016. In the meantime, the UK government will encourage applications for medicines licences for nicotine-containing products and will make best use of the flexibilities within the existing framework to enable licensed products to be available. For further details, see the MHRA website.
Products that contain nicotine but do not contain tobacco and so deliver nicotine without the harmful toxins found in tobacco. Some, such as nicotine replacement therapy (NRT), are regulated by the MHRA (see licensed nicotine-containing products). Unlicensed products that are currently being marketed, such as electronic cigarettes, and products new to the market will need a medicines licence once the European Commission's revised Tobacco Products Directive comes into effect in the UK (this is expected to be in 2016). For further details, see the MHRA website.
Secondary care refers to all publicly-funded secondary and tertiary care facilities, including buildings, grounds and vehicles. It covers drug and alcohol services in secondary care, emergency care, inpatient, residential and long-term care for severe mental illness in hospitals, psychiatric and specialist units and secure hospitals and planned specialist medical care or surgery. It also includes maternity care provided in hospitals, maternity units, outpatient clinics and in the community. It can be planned or emergency care. Planned secondary care generally follows a referral from a primary care provider, such as a GP.

Glossary

a carbon monoxide assessment is a non-invasive biochemical method for measuring CO from expired breath; It can detect exposure to CO which may come from tobacco smoke, traffic emissions or leaky gas appliances
a formulary is a list of healthcare treatments and drugs approved for use within a health economy, service or organisation
a joint strategic needs assessment provides a profile of the health and social care needs of a local population – joint strategic needs assessments are used to develop joint health and wellbeing strategies; they are also used for commissioning to improve health outcomes and reduce health inequalities
nicotine replacement therapy are licensed nicotine-containing products for use as a stop smoking aid and for temporary abstinence, as outlined in the British national formulary; they include: transdermal patches, gum, inhalation cartridges, sublingual tablets and a mouth and nasal spray
pharmacotherapy is the treatment of addiction through the administration of drugs (stop smoking advisers and healthcare professionals may recommend and prescribe licensed nicotine-containing products, varenicline or bupropion as an aid to help people to stop smoking; licensed nicotine-containing products may also be offered to support temporary abstinence from smoking in the secondary care setting)
smokefree means air that is free of smoke and applies to hospital buildings, grounds and vehicles
stopping smoking with the intention to stop permanently; stopping may be abrupt or by cutting down before stopping
stop smoking services provide a combination of behavioural support and pharmacotherapy to aid smoking cessation (NHS behavioural support is free but the pharmacotherapy may incur a standard prescription charge; the evidence-based treatment is based on the National Centre for Smoking Cessation and Training (NCSCT) standard programme and involves practitioners trained to their standard or equivalent)
not smoking for a limited period of time – this could be for a particular event, for example, during a hospital stay or contact with secondary care providers, or in preparation for planned use of secondary care services such as elective surgery, or while visiting or working in a secondary care setting

Paths in this pathway

Pathway created: November 2013 Last updated: November 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

Recently viewed