A-Z
Topics
Latest

Tobacco use

About

What is covered

This NICE Pathway covers support to stop smoking for everyone aged 12 and over, and to help reduce people's harm from smoking if they are not ready to stop in one go. It also covers ways to prevent children, young people and young adults aged 24 and under from taking up smoking. The NICE Pathway brings together and updates all of NICE's previous guidance on using tobacco, including smokeless tobacco. It covers NRT and e-cigarettes, but does not cover using tobacco products such as 'heat not burn' tobacco to help people stop smoking or reduce their harm from smoking.

Engagement with tobacco industry organisations

The UK Government is a signatory and party to the World Health Organization Framework Convention on Tobacco Control (FCTC). The development of this NICE Pathway complies with NICE's obligations under Article 5.3 of the FCTC.

Updates

Updates to this NICE Pathway

30 November 2021 Updated on publication of the NICE guideline update on tobacco: preventing uptake, promoting quitting and treating dependence (NICE guideline NG209).

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 preventing uptake of smoking, promoting quitting and treating tobacco dependence in an interactive flowchart

What is covered

This NICE Pathway covers support to stop smoking for everyone aged 12 and over, and to help reduce people's harm from smoking if they are not ready to stop in one go. It also covers ways to prevent children, young people and young adults aged 24 and under from taking up smoking. The NICE Pathway brings together and updates all of NICE's previous guidance on using tobacco, including smokeless tobacco. It covers NRT and e-cigarettes, but does not cover using tobacco products such as 'heat not burn' tobacco to help people stop smoking or reduce their harm from smoking.

Engagement with tobacco industry organisations

The UK Government is a signatory and party to the World Health Organization Framework Convention on Tobacco Control (FCTC). The development of this NICE Pathway complies with NICE's obligations under Article 5.3 of the FCTC.

Updates

Updates to this NICE Pathway

30 November 2021 Updated on publication of the NICE guideline update on tobacco: preventing uptake, promoting quitting and treating dependence (NICE guideline NG209).

Sources

NICE guidance and other sources used to create this interactive flowchart.
Varenicline for smoking cessation (2007) NICE technology appraisal guidance 123
Smoking: harm reduction (2015) NICE quality standard 92
Smoking: reducing and preventing tobacco use (2015) NICE quality standard 82
Smoking: supporting people to stop (2013, updated 2021) NICE quality standard 43
Antenatal care (2012, updated 2021) NICE quality standard 22
Lung cancer in adults (2012, updated 2019) NICE quality standard 17

Quality standards

Smoking: harm reduction

These quality statements are taken from the smoking: harm reduction quality standard. The quality standard defines clinical best practice for smoking: harm reduction and should be read in full.

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

Offering harm-reduction approaches

This quality statement is taken from the smoking: harm-reduction quality standard. The quality standard defines clinical best practice in smoking: harm-reduction and should be read in full.

Quality statement

People who do not want, or are not ready, to stop smoking are offered a harm-reduction approach to smoking.

Rationale

The best way for a person to reduce illness and mortality associated with smoking is to stop smoking in one go. However, not everyone who smokes feels able to, or wants to, stop, or they may want to stop but without giving up nicotine. It is important that these people are encouraged to try a harm-reduction approach to smoking. In addition, it is important to raise the option of harm-reduction approaches as widely as possible – that is, outside stop-smoking services, because people who do not want, or are not ready, to stop smoking are less likely to access these services.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements and written protocols to ensure that people who do not want, or are not ready, to stop smoking are offered a harm-reduction approach to smoking.
Data source: Local data collection.
Process
Proportion of people identified as not wanting or not ready to stop smoking who are offered a harm-reduction approach to smoking.
Numerator – the number in the denominator who are offered a harm-reduction approach to smoking.
Denominator – the number of people identified as not wanting or not ready to stop smoking.
Data source: Local data collection.
Outcome
Uptake of smoking harm-reduction approaches.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as primary and secondary healthcare providers, pharmacies, residential and domiciliary care providers, providers of stop-smoking support and providers of secure mental health services) ensure that healthcare and public health practitioners are trained to offer and explain harm-reduction approaches to people who do not want, or are not ready, to stop smoking.
Healthcare and public health practitioners (such as pharmacists, GPs, nurses, clinicians in NHS services, mental health care staff, staff in drug and alcohol services, stop-smoking advisers, ophthalmic practitioners and dental professionals) who determine whether service users smoke ensure that they understand and are able to explain harm-reduction approaches, and offer harm-reduction approaches to people who do not want, or are not ready, to stop smoking while still prioritising stopping smoking as the best approach to take.
Commissioners (such as clinical commissioning groups, local authorities and NHS England) ensure that they commission services from providers that train healthcare and public health practitioners to offer and explain harm-reduction approaches to people who do not want, or are not ready, to stop smoking.
People who smoke but are not ready or do not want to quit are offered ways to reduce the harm from smoking that do not necessarily mean having to give up nicotine. These are called ‘harm-reduction approaches’, and include things like cutting down, using medicinally licensed nicotine-containing products (such as patches, gum and tablets) and stopping smoking for a while.

Source guidance

Definitions of terms used in this quality statement

Harm-reduction approach
Harm-reduction approaches to smoking include:
Cutting down before stopping smoking:
  • with the help of 1 or more medicinally licensed nicotine-containing products (the products may be used for as long as needed to prevent relapse to previous levels of smoking)
  • without using medicinally licensed nicotine-containing products.
Smoking reduction:
  • with the help of 1 or more medicinally licensed nicotine-containing products (the products may be used for as long as needed to prevent relapse to previous levels of smoking)
  • without using medicinally licensed nicotine-containing products.
Temporarily not smoking:
  • with the help of 1 or more medicinally licensed nicotine-containing products
  • without using medicinally licensed nicotine-containing products.
People who do not want, or are not ready, to stop smoking
This includes people who:
  • may not be able (or do not want) to stop smoking in one go
  • may not be ready to stop smoking, but want to reduce the amount they smoke.
[Adapted from NICE’s guideline on tobacco, recommendations 1.15.2 and 1.15.10]
Stop in one go
This is the standard approach for stop-smoking support. The person makes a commitment to stop smoking on or before a particular date (the ‘quit date’). This may or may not involve the use of stop-smoking pharmacotherapy before the quit date and for a period of time afterwards, depending on the person’s needs. [Adapted from NICE’s guideline on tobacco, terms used in this guideline; stop in one go]

Equality and diversity considerations

Advice should be culturally appropriate and readily available to people with additional needs such as physical, sensory or learning disabilities and people who do not speak or read English, and to people in groups identified as having a higher smoking prevalence. These include LGBT+ people, people with mental health problems, people in closed institutions (such as secure mental health units and custodial sites), people who are homeless and people from lower socioeconomic groups. 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 or the equivalent standards for the devolved nations.

Advice about nicotine

This quality statement is taken from the smoking: harm-reduction quality standard. The quality standard defines clinical best practice in smoking: harm-reduction and should be read in full.

Quality statement

People who do not want, or are not ready, to stop smoking are advised that health problems associated with smoking are caused primarily by components in tobacco smoke other than nicotine.

Rationale

Nicotine is the main addictive chemical that makes stopping smoking difficult, but it is primarily the toxins and carcinogens in tobacco smoke – not the nicotine – that cause illness and death. People who smoke often have misconceptions about the role of nicotine in causing harm, and this can act as a barrier that prevents them from considering the use of medicinally licensed nicotine-containing products.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements and protocols to ensure that people who do not want, or are not ready, to stop smoking are advised that health problems associated with smoking are caused primarily by components in tobacco smoke other than nicotine.
Data source: Local data collection.
Process
Proportion of people identified as not wanting or not ready to stop smoking who are advised that health problems associated with smoking are caused primarily by components in tobacco smoke other than nicotine.
Numerator – the number in the denominator who are advised that health problems associated with smoking are caused primarily by components in tobacco smoke other than nicotine.
Denominator – the number of people identified as not wanting or not ready to stop smoking.
Data source: Local data collection.
Outcome
Awareness of people who smoke that health problems associated with smoking are caused primarily by components in tobacco smoke other than nicotine.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as primary and secondary healthcare providers, pharmacies, residential and domiciliary care providers, providers of stop-smoking support and providers of secure mental health services) ensure that healthcare and public health practitioners are trained to advise people who do not want, or are not ready, to stop smoking that health problems associated with smoking are caused primarily by components in tobacco smoke other than nicotine.
Healthcare and public health practitioners (such as pharmacists, GPs, nurses, clinicians in NHS services, mental health care staff, staff in drug and alcohol services, stop-smoking advisers, ophthalmic practitioners and dental professionals) who determine whether service users smoke advise people who do not want, or are not ready, to stop smoking that health problems associated with smoking are caused primarily by components in tobacco smoke other than nicotine.
Commissioners (such as clinical commissioning groups, local authorities and NHS England) ensure that they commission services from providers that train healthcare and public health practitioners to advise people who do not want, or are not ready, to stop smoking that health problems associated with smoking are caused primarily by components in tobacco smoke other than nicotine.
People who are not ready or do not want to quit smoking are told that nicotine is not the main cause of health problems associated with smoking.

Source guidance

Definitions of terms used in this quality statement

People who do not want, or are not ready, to stop smoking
This includes people who:
  • may not be able (or do not want) to stop smoking in one go
  • may not be ready to stop smoking, but want to reduce the amount they smoke.
[Adapted from NICE’s guideline on tobacco, recommendations 1.15.2 and 1.15.10]

Equality and diversity considerations

Advice should be culturally appropriate and readily available to people with additional needs such as physical, sensory or learning disabilities and people who do not speak or read English, and to people in groups identified as having a higher smoking prevalence. These include LGBT+ people, people with mental health problems, people in closed institutions (such as secure mental health units and custodial sites), people who are homeless and people from lower socioeconomic groups. 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 or the equivalent standards for the devolved nations.

Advice about medicinally licensed nicotine-containing products

This quality statement is taken from the smoking: harm-reduction quality standard. The quality standard defines clinical best practice in smoking: harm-reduction and should be read in full.

Quality statement

People who do not want, or are not ready, to stop smoking are advised about and supported to obtain medicinally licensed nicotine-containing products.

Rationale

It is important to explain the potential benefits of and issues about using medicinally licensed nicotine-containing products, and also to ensure that medicinally licensed nicotine-containing products are readily available to people who want to use them to reduce harm from smoking.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements that people who do not want, or are not ready, to stop smoking are advised about and supported to obtain medicinally licensed nicotine-containing products.
Data source: Local data collection.
Process
a) Proportion of people identified as not wanting, or not ready, to stop smoking who are advised about using medicinally licensed nicotine-containing products.
Numerator – the number in the denominator who are advised about using medicinally licensed nicotine-containing products.
Denominator – the number of people identified as not wanting, or not ready, to stop smoking.
Data source: Local data collection.
b) Proportion of people identified as not wanting, or not ready, to stop smoking who are supported to obtain medicinally licensed nicotine-containing products.
Numerator – the number in the denominator who are supported to obtain medicinally licensed nicotine-containing products.
Denominator – the number of people identified as not wanting, or not ready, to stop smoking.
Data source: Local data collection.
Outcome
Uptake of medicinally licensed nicotine-containing products.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as primary and secondary healthcare providers, pharmacies, residential and domiciliary care providers, providers of stop-smoking support and providers of secure mental health services) ensure that healthcare and public health practitioners are trained to advise people who do not want, or are not ready, to stop smoking about using medicinally licensed nicotine-containing products to reduce the harm caused by smoking, and to either prescribe or supply medicinally licensed products or tell people where they can buy them.
Healthcare and public health practitioners (such as pharmacists, GPs, nurses, clinicians in NHS services, mental health care staff, staff in drug and alcohol services, stop-smoking advisers, ophthalmic practitioners and dental professionals) who determine whether service users smoke advise people who do not want, or are not ready, to stop smoking about using medicinally licensed nicotine-containing products to reduce the harm caused by smoking, and either prescribe or supply medicinally licensed products or tell people where they can buy them.
Commissioners (such as clinical commissioning groups, local authorities and NHS England) ensure that they commission services from providers that train healthcare and public health practitioners to advise people who do not want, or are not ready, to stop smoking about using medicinally licensed nicotine-containing products to reduce the harm caused by smoking, and to either prescribe or supply medicinally licensed products or tell people where they buy them.
People who are not ready or do not want to quit smoking get advice about using medicinally licensed nicotine-containing products as a way of reducing the harm from smoking, both for them and for those around them. They are also helped to get hold of medicinally licensed nicotine-containing products – for example, by being prescribed these products or being told where they can buy them.

Source guidance

Definitions of terms used in this quality statement

People who do not want, or are not ready, to stop smoking
This includes people who:
  • may not be able (or do not want) to stop smoking in one go
  • may not be ready to stop smoking, but want to reduce the amount they smoke.
[Adapted from NICE’s guideline on tobacco, recommendations 1.15.2 and 1.15.10]
Advice about using medicinally licensed nicotine-containing products
Reassure people who smoke that medicinally licensed nicotine-containing products are a safe, effective way to reduce the amount they smoke or to cut down before stopping. Also:
  • advise them that these products can be used as a complete or partial substitute for tobacco, either in the short or long term
  • explain that using these products also helps avoid compensatory smoking and increases their chances of stopping in the longer term
  • reassure them that it is better to use these products and reduce the amount they smoke than to continue smoking at their current level.
[NICE’s guideline on tobacco, recommendation 1.15.4]
Medicinally licensed nicotine-containing products
Nicotine-containing products that have been given marketing authorisation by the Medicines and Healthcare products Regulatory Agency (MHRA). At the time of publication, nicotine replacement therapy products were the only type of medicinally licensed nicotine-containing product on the market. Nicotine replacement therapy includes transdermal patches, gum, inhalation cartridges, sublingual tablets, lozenges, mouth spray and nasal spray. [Adapted from NICE’s guideline on tobacco, terms used in this guideline; medicinally licensed nicotine-containing products and nicotine replacement therapy]
If other nicotine-containing products (such as e-cigarettes) gain licensing authorisation in the future, this quality statement will be reviewed.
Supported to obtain medicinally licensed nicotine-containing products
If possible, supply or prescribe medicinally licensed nicotine-containing products. Otherwise, encourage people to ask their GP or pharmacist for them, or tell them where they can buy the products themselves. [NICE’s guideline on tobacco, recommendation 1.15.6]

Equality and diversity considerations

Advice should be culturally appropriate and readily available to people with additional needs, such as physical, sensory or learning disabilities and people who do not speak or read English, and to people in groups identified as having a higher smoking prevalence. These include LGBT+ people, people with mental health problems, people in closed institutions (such as secure mental health units and custodial sites), people who are homeless and people from lower socioeconomic groups. 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 or the equivalent standards for the devolved nations.

Integrating harm-reduction approaches into stop-smoking support

This quality statement is taken from the smoking: harm-reduction quality standard. The quality standard defines clinical best practice in smoking: harm-reduction and should be read in full.

Quality statement

Providers of stop-smoking support offer harm-reduction approaches alongside existing approaches to stopping smoking in one go.

Rationale

Stopping smoking in one go is the standard approach currently offered by stop-smoking support, with harm-reduction approaches to smoking being a relatively underused approach. The integration of harm-reduction approaches to smoking into current services will ensure that they are available as an option to people who use these services and who do not want, or are not ready, to stop smoking in one go. While it is important that stop-smoking services offer harm-reduction approaches to smoking, this should not be the only place where these approaches are offered. As set out in quality statement 1, healthcare and public health practitioners outside stop-smoking services should also offer harm-reduction approaches (when appropriate) to reach people who do not use these services.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements that providers of stop-smoking support offer harm-reduction approaches to smoking alongside existing approaches to stopping smoking in one go.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (providers of stop-smoking’ support) train healthcare and public health practitioners to offer harm-reduction approaches to people who do not want, or are not ready, to stop smoking.
Healthcare and public health practitioners ensure that they offer harm-reduction approaches to people who do not want, or are not ready, to stop smoking.
Commissioners (local authorities) ensure that service specifications include a requirement that providers of stop-smoking support offer harm-reduction approaches to smoking to people who do not want, or are not ready, to stop smoking.
People who are having stop-smoking support have the option of harm-reduction approaches if they do not think they can quit smoking in one go or do not want to quit.

Source guidance

Definitions of terms used in this quality statement

Harm-reduction approaches
Harm-reduction approaches to smoking include:
Cutting down before stopping smoking:
  • with the help of 1 or more medicinally licensed nicotine-containing products (the products may be used for as long as needed to prevent relapse to previous levels)
  • without using medicinally licensed nicotine-containing products.
Smoking reduction:
  • with the help of 1 or more medicinally licensed nicotine-containing products (the products may be used for as long as needed to prevent relapse to previous levels)
  • without using medicinally licensed nicotine-containing products.
Temporarily not smoking:
  • with the help of 1 or more medicinally licensed nicotine-containing products
  • without using medicinally licensed nicotine-containing products.
Stop smoking in one go
The standard approach for stop-smoking support. The person makes a commitment to stop smoking on or before a particular date (the ‘quit date’). This may or may not involve the use of stop-smoking pharmacotherapy before the quit date and for a limited time afterwards, depending on the person’s needs. [Adapted from NICE’s guideline on tobacco, terms used in this guideline; stop in one go]
Stop-smoking support
Interventions and support to stop smoking, regardless of how services are commissioned or set up. [NICE’s guideline on tobacco, terms used in this guideline; stop-smoking support]

Equality and diversity considerations

LGBT+ people, people with mental health problems, people in closed institutions (such as secure mental health units and custodial sites), people who are homeless and people from lower socioeconomic groups have higher smoking prevalence rates than the general population. Stop-smoking services should be promoted, accessible and commissioned to address this need. 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 or the equivalent standards for the devolved nations.

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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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 covers the national prevalence of smoking among young people aged 16 to 19 and secondary school students (mostly aged 11 to 15).

What the quality statement means for different audiences

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

Source guidance

Definitions of terms used in this quality statement

Schools and colleges
This covers:
  • 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.
[Adapted from NICE’s guideline on tobacco, terms used in this guideline; schools]
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 on school-based programmes for preventing smoking 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.

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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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 different audiences

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

Source guidance

Definitions of terms used in this quality statement

Schools and colleges
This covers:
  • 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.
[Adapted from NICE’s guideline on tobacco, terms used in this guideline; schools]

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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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: Local data collection. Data on number of test purchases resulting in a sale is reported in the Tobacco Control Survey, England from the 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: Local data collection. Data on actions taken where breaches of the legislation were found are reported in the Tobacco Control Survey, England from the 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: Local data collection.
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: Local data collection. Data on numbers of prosecutions where breaches of the legislation were found is reported in the Tobacco Control Survey, England from the Chartered Trading Standards Institute.
Outcome
Incidence of underage tobacco sales.
Data source: Local data collection.

What the quality statement means for different audiences

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

Source guidance

Definitions of terms used in this quality statement

Identifying retailers
Local authorities, trading standards, the police, HM Revenue and Customs, voluntary and community groups work in partnership 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, legislation prohibiting under age tobacco sales. [Adapted from NICE’s guideline on tobacco, recommendations 1.3.1, 1.3.3, 1.3.4 and expert opinion]
Taking actions against retailers
Actions taken against retailers include:
  • Making test purchases each year, using local data to detect breaches in the law and auditing the breaches regularly to ensure consistent good practice across all local authorities.
  • Running campaigns for retailers to publicise legislation prohibiting under age tobacco sales.
  • Prosecuting retailers who persistently break the law.
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. [NICE’s guideline on tobacco, recommendations 1.3.2 and 1.3.4, 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 support 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 support, employers are likely to realise substantial benefits, such as increased productivity, decreased sickness rates and improved adherence to smokefree policies.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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 different audiences

Commissioners of stop-smoking support ensure that there is capacity to deliver support to employers who want to help their employees to stop smoking.
All employers encourage employees who smoke (including students, apprentices and volunteers) to access stop-smoking support. They facilitate employees to access stop-smoking support by allowing them to attend during working hours without loss of pay. Employers may choose to organise on site stop-smoking support if that is feasible.
Employees who smoke can attend stop-smoking support during working hours, without losing pay.
Stop-smoking support providers 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 support is provided on site and there is increased demand on the service.

Source guidance

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 support.

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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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 different audiences

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.

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’s guideline on tobacco, recommendation 1.21.1 and terms used in this guideline; secondary care]

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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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 different audiences

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.
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’s guideline on tobacco, recommendation 1.21.1 and terms used in this guideline; secondary care]

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.

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 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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence of local arrangements to ensure that stop-smoking pharmacotherapies and medicinally 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 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 stop-smoking pharmacotherapies and medicinally licensed nicotine-containing products.
Numerator – the number in the denominator that stock stop-smoking pharmacotherapies and medicinally 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 different audiences

Directors and senior managers of secondary care services or their representatives ensure that compliance with a smokefree policy is facilitated by a range of 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 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 nicotine-containing products and stop-smoking pharmacotherapies on site.
Patients in secondary healthcare services can obtain a range of nicotine-containing products and stop-smoking pharmacotherapies on site at all times. This helps them follow the smokefree policy within the healthcare grounds.
Visitors in secondary healthcare services can obtain a range of nicotine-containing products on site at all times. This helps them follow the smokefree policy within the healthcare grounds.

Source guidance

Definitions of terms used in this quality statement

Secondary healthcare settings
All publicly funded secondary 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 in hospitals, maternity units, outpatient clinics and in the community. [NICE’s guideline on tobacco, terms used in this guideline; secondary care]
Nicotine-containing products
Products that contain nicotine but do not contain tobacco and so deliver nicotine without the harmful toxins found in tobacco. This currently includes nicotine replacement therapy which has been medicinally licensed for smoking cessation by the Medicines and Healthcare products Regulatory Agency (MHRA) and nicotine-containing e-cigarettes. Currently there are no licensed nicotine-containing e-cigarettes on the market. Nicotine-containing e-cigarettes on general sale are regulated under the Tobacco and Related Product Regulations by the MHRA. For further details see the MHRA website. Different forms of nicotine replacement therapy include:
  • transdermal patches
  • gum
  • inhalation cartridges
  • sublingual tablets
  • lozenges
  • mouth spray
  • nasal spray.
[Adapted from NICE’s guideline on tobacco, terms used in this guideline; nicotine-containing products and nicotine replacement therapy]
If alternative nicotine-containing products (such as e-cigarettes) gain licensing authorisation in the future, this quality statement will be reviewed.
Stop-smoking pharmacotherapies
This covers medication licensed for smoking cessation such as varenicline or bupropion, as well as nicotine-replacement therapy. In November 2021, varenicline was unavailable in the UK. See the MHRA alert on varenicline. [NICE’s guideline on tobacco, terms used in this guideline; pharmacotherapies]

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. 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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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 different audiences

Local authorities supported by government bodies 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.
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:
  • using regional and local channels
  • writing articles, commissioning newsworthy research and issuing press releases
  • using posters, brochures and other materials
  • production and dissemination of e-information and email footers
  • using digital media and dissemination of information through social media streams
  • completion of radio and television interviews
  • delivery of local promotional events in community settings, for example, sports stadia, supermarkets, shopping centres and markets.
[NICE’s guideline on tobacco, recommendations 1.1.5 and 1.2.2 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.

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.

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.
Illicit tobacco includes:
  • 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.

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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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: Local data collection. Data for general practice is published under SMOK001 collected as part of indicators no longer in QOF (INLIQ).
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: Local data collection.

What the quality statement means for different audiences

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

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.
Advice
This can vary by healthcare setting. In the context of primary care settings, this would involve opportunistic advice offered to people who smoke about the interventions 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 local stop-smoking support. People who smoke should be advised to stop smoking in a way that is sensitive to their preferences and needs. They should be advised that stopping smoking in one go is the best approach.
The National Centre for Smoking Cessation and Training offers a practitioner training and assessment programme. [Adapted from NICE’s guideline on tobacco, recommendations 1.11.2, 1.12.1, 1.13.1, 1.14.3 and 1.14.5]

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. 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 or the equivalent standards for the devolved nations.
Advice may include referral to evidence-based stop-smoking support. Such support 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.
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 to17 who smoke should be offered information, advice and support on how to stop smoking and be encouraged to use local evidence-based stop-smoking support, if available.
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 statement has been removed. For more details, see update information in NICE's quality standard on smoking: supporting people to stop.

Stop-smoking support

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 in contact with healthcare practitioners who provide stop-smoking support are offered stop-smoking advice and interventions.

Rationale

People who smoke should have access to advice and interventions to help them to stop smoking, as appropriate for their age or if they are pregnant. They should be advised that varenicline, a combination of short-acting and long-acting nicotine replacement therapy or nicotine containing e-cigarettes, when combined with behavioural support, are more likely to result in them successfully stopping smoking.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that people in contact with healthcare practitioners who provide stop-smoking support are offered stop-smoking advice and interventions.
Data source: Local data collection.
Process
Proportion of people in contact with healthcare practitioners who provide stop-smoking support who are offered stop-smoking advice and interventions.
Numerator – the number of people in the denominator who are offered stop-smoking advice and interventions.
Denominator – the number of people in contact with healthcare practitioners who provide stop-smoking support.

What the quality statement means for different audiences

Service providers ensure that systems are in place for people in contact with healthcare practitioners who provide stop-smoking support to be offered stop-smoking advice and interventions.
Healthcare practitioners who provide stop-smoking support offer stop-smoking advice and interventions to people who smoke.
Commissioners ensure that they commission stop-smoking support that offers stop-smoking advice and treatment.
People seeing healthcare practitioners who provide stop-smoking support are offered stop-smoking advice and treatment.

Source guidance

Definitions of terms used in this quality statement

Stop-smoking advice and interventions
The following should be accessible to adults who smoke:
In November 2021, varenicline was unavailable in the UK. See the Medicines and Healthcare products Regulatory Agency (MHRA) alert on varenicline.
People who smoke should be advised (as appropriate for their age) that, when combined with behavioural support, the following options are more likely to result in them successfully stopping smoking:
Nicotine replacement therapy should be considered alongside behavioural support to help women stop smoking in pregnancy. Varenicline or bupropion should not be offered to pregnant or breastfeeding women or people under 18. [NICE’s guideline on tobacco, recommendations 1.12.2, 1.12.7, 1.20.6 and 1.20.11 and terms used in this guideline; pharmacotherapies]
Stop smoking support
Interventions and support to stop smoking regardless of how services are commissioned or set up.

Equality and diversity considerations

Pregnant or breastfeeding women should not be offered varenicline or bupropion. Nicotine replacement therapy should be considered alongside behavioural support.
Young people aged under 18 should not be offered varenicline or bupropion. Nicotine replacement therapy should be considered alongside behavioural support.

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 choose 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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that people who seek support to stop smoking and who choose 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 choose 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 choose to take pharmacotherapy.
Data source: Local data collection. Statistics on NHS Stop Smoking Services in England from NHS Digital reports on pharmacotherapy received.

What the quality statement means for different audiences

Service providers ensure that systems are in place so that people who seek support to stop smoking and who choose 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 choose 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 choose to take pharmacotherapy.
People who seek support to stop smoking and who choose to take medicine to help them quit are offered a full course of treatment.

Source guidance

Definitions of terms used in this quality statement

Pharmacotherapy
This covers medication licensed for smoking cessation such as varenicline or bupropion, as well as nicotine replacement therapy. In November 2021, varenicline was unavailable in the UK. See the MHRA alert on varenicline.
Nicotine replacement therapy should be considered alongside behavioural support to help women stop smoking in pregnancy. Varenicline or bupropion should not be offered to pregnant or breastfeeding women or people under 18. [NICE’s guideline on tobacco, recommendations 1.12.4, 1.20.6 and 1.20.11 and terms used in this guideline; pharmacotherapies]

Equality and diversity considerations

There should be a discussion about risks and benefits of using NRT in young people aged 12 to 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 have a carbon monoxide test 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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that people who smoke who have set a quit date have a carbon monoxide test 4 weeks after the quit date.
Data source: Local data collection.
Process
Proportion of people who smoke who have set a quit date who had a carbon monoxide test 4 weeks after the quit date.
Numerator – the number of people in the denominator who had a carbon monoxide test 4 weeks after the quit date.
Denominator – the number of people who smoke who have set a quit date.
Data source: Local data collection. Statistics on NHS Stop Smoking Services in England from NHS Digital reports on people setting a quit date and outcome per 100,000 smokers.
Outcome
4-week quit rates.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place so that people who smoke who have set a quit date have a carbon monoxide test 4 weeks after the quit date.
Healthcare practitioners ensure that people who smoke who have set a quit date have a carbon monoxide test 4 weeks after the quit date.
Commissioners ensure that they commission services for people who smoke who have set a quit date to have a carbon monoxide test 4 weeks after the quit date.
People who smoke who have set a quit date have a carbon monoxide breath test 4 weeks after their quit date.

Source guidance

Definitions of terms used in this quality statement

Carbon monoxide test
Self-reported smoking abstinence is checked using a carbon monoxide test. Success is defined as the person having less than 10 parts per million (ppm) of carbon monoxide in their exhaled breath at 4 weeks after the quit date. This does not imply that treatment should stop at 4 weeks.
Urine or saliva cotinine tests should be used in pregnant women, if possible, because these are more accurate than carbon monoxide tests. [NICE’s guideline on tobacco, recommendations 1.20.2 and 1.22.23]

Equality and diversity considerations

If possible, pregnant women should have a urine or saliva cotinine test to biochemically validate smoking abstinence as these are more accurate than carbon monoxide tests.

Services – access to antenatal care

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

Quality statement

Pregnant women are supported to access antenatal care, ideally by 10 weeks 0 days.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence of local services that ensure antenatal care is readily and easily accessible.
Data source: Local data collection. The baseline assessment tool for NICE’s guideline on pregnancy and complex social factors can be used to assess current activity related to recording information for women presenting to antenatal care with complex social needs to inform mapping of the local population and to guide service provision.
b) Evidence of local arrangements to encourage pregnant women to access and maintain contact with antenatal care services.
Data source: Local data collection. The baseline assessment tool for NICE’s guideline on pregnancy and complex social factors can be used to assess current activity related to recording information for women presenting to antenatal care with complex social needs to inform mapping of the local population and to guide service provision.
Process
Proportion of pregnant women missing a scheduled antenatal appointment who are followed up within locally defined timescales.
Numerator – the number in the denominator followed up within locally defined timescales.
Denominator – the number of pregnant women missing a scheduled antenatal appointment.
Data source: Local data collection.
Outcome
a) Pregnant women accessing antenatal care who are seen for booking by 10 weeks 0 days.
Data source: The NHS Digital Maternity Services Data Set collects data on booking appointment dates and estimated dates of delivery. The Care Quality Commission Maternity Services Survey asks the question ‘Roughly how many weeks pregnant were you when you had your ‘booking’ appointment (the appointment where you were given access to your pregnancy notes)?’.
b) Pregnant women accessing antenatal care who are seen for booking by 12 weeks 6 days.
Data source: The NHS Digital Maternity Services Data Set collects data on booking appointment dates and estimated dates of delivery. The Care Quality Commission Maternity Services Survey asks the question ‘Roughly how many weeks pregnant were you when you had your ‘booking’ appointment (the appointment where you were given access to your pregnancy notes)?’.
c) Pregnant women accessing antenatal care who are seen for booking by 20 weeks 0 days.
Data source: The NHS Digital Maternity Services Data Set collects data on booking appointment dates and estimated dates of delivery. The Care Quality Commission Maternity Services Survey asks the question ‘Roughly how many weeks pregnant were you when you had your ‘booking’ appointment (the appointment where you were given access to your pregnancy notes)?’.
d) Median gestation at booking.
Data source: The NHS Digital Maternity Services Data Set collects data on booking appointment dates and estimated dates of delivery. The Care Quality Commission Maternity Services Survey asks the question ‘Roughly how many weeks pregnant were you when you had your ‘booking’ appointment (the appointment where you were given access to your pregnancy notes)?’.
e) Pregnant women accessing antenatal care attend at least the recommended number of antenatal appointments.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place to support pregnant women to access antenatal care, ideally by 10 weeks 0 days.
Health and social care professionals support pregnant women to access antenatal care, ideally by 10 weeks 0 days. This includes following up women who have missed a scheduled antenatal appointment.
Commissioners ensure that they commission services that are readily and easily accessible and that support pregnant women to access antenatal care, ideally by 10 weeks 0 days.
Pregnant women are encouraged to see a healthcare professional about their pregnancy as early as possible and have regular check-ups from their midwife or doctor throughout their pregnancy (antenatal care). This may include being contacted by their midwife or doctor if they miss a check-up.

Source guidance

Definitions of terms used in this quality statement

Support to access antenatal care
Commissioners and providers should ensure that antenatal care can be started in a variety of straightforward ways, depending on women’s needs and circumstances, for example, by self-referral, referral by a GP, midwife or another healthcare professional or through a school nurse, community centre or refugee hostel.
At the first antenatal (booking) appointment, discuss antenatal care with the woman (and her partner) and provide her schedule of antenatal appointments (plan 10 routine antenatal appointments with a midwife or doctor for nulliparous women and 7 for parous women).
At the first antenatal (booking) appointment (and later if appropriate), discuss and give information on:
  • what antenatal care involves and why it is important
  • the planned number of antenatal appointments
  • where antenatal appointments will take place
  • which healthcare professionals will be involved in antenatal appointments
  • how to contact the midwifery team for non-urgent advice
  • how to contact the maternity service about urgent concerns, such as pain and bleeding.
[NICE’s guideline on antenatal care, recommendations 1.1.1, 1.1.7, 1.1.8, 1.3.7 and 1.3.8]
Follow-up after a missed appointment may be undertaken by the maternity service or other community-based service the woman is in contact with, such as a children’s centre, addiction service or GP. Follow-up should be via a method of contact that is appropriate to the woman, which may include:
  • text message
  • letter
  • telephone
  • community or home visit.
[NICE’s guideline on pregnancy and complex social factors, recommendation 1.2.8 and expert opinion]

Equality and diversity considerations

Pregnant women include women with complex social needs who may be less likely to access or maintain contact with antenatal care services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol and/or drugs)
  • have recently arrived as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that localities give special consideration to these groups of women within the measures. NICE’s guideline on pregnancy and complex social factors has recommendations about how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.

Services – continuity of care

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

Quality statement

Pregnant women are cared for by a named midwife throughout their pregnancy.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence of local arrangements and audit to ensure that pregnant women are cared for by a named midwife throughout their pregnancy.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that systems are in place to coordinate a pregnant woman’s care should her named midwife not be available.
Data source: Local data collection.
Process
Proportion of pregnant women with a named midwife.
Numerator – the number in the denominator with a named midwife.
Denominator – the number of pregnant women accessing antenatal care.
Data source: Local data collection.
Outcome
Pregnant women’s satisfaction with the continuity of their antenatal care.
Data source: Local data collection. The Care Quality Commission Maternity Services Survey asks the question ‘At your antenatal check-ups, did you see the same midwife every time?’

What the quality statement means for different audiences

Service providers ensure that systems are in place to enable pregnant women to be cared for by a named midwife throughout their pregnancy.
Healthcare professionals follow local systems and guidance to provide continuity of care to pregnant women through the provision of a named midwife.
Commissioners ensure they commission services that enable pregnant women to be cared for by a named midwife throughout their pregnancy.
Pregnant women are cared for a by a named midwife throughout their pregnancy.

Source guidance

Antenatal care. NICE guideline NG201 (2021), recommendation 1.1.12

Definitions of terms used in this quality statement

Named midwife
Having continuity of carer means that a trusting relationship can be developed between the woman and the healthcare professional who cares for her. The Better Births report by the National Maternity Review defines continuity of carer as consistency in the midwifery team (between 4 and 8 individuals) that provides care for the woman and her baby throughout pregnancy, labour and the postnatal period. A named midwife coordinates the care and takes responsibility for ensuring that the needs of the woman and her baby are met throughout the antenatal, intrapartum and postnatal periods [NICE’s guideline on antenatal care, terms used in this guideline]

Services – record keeping

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

Quality statement

Pregnant women have a complete record of the minimum set of antenatal test results in their maternity notes.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence of local arrangements to ensure that pregnant women have a complete record of the minimum set of antenatal test results in their maternity notes.
Data source: Local data collection.
b) Evidence of local audit to monitor the completeness and accuracy of antenatal test results in women’s maternity notes.
Data source: Local data collection.
Process
Proportion of pregnant women accessing antenatal care who have a complete record of the minimum set of antenatal test results in their maternity notes, appropriate to their stage of pregnancy.
Numerator – the number in the denominator with a complete record of the minimum set of antenatal test results in their maternity notes, appropriate to their stage of pregnancy.
Denominator – the number of pregnant women accessing antenatal care.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place to maintain a complete record of the minimum set of antenatal test results in women’s maternity notes.
Healthcare professionals ensure that women have a complete record of the minimum set of antenatal test results in their maternity notes.
Commissioners ensure that they commission services that maintain a complete record of the minimum set of antenatal test results in women’s maternity notes.
Pregnant women are given a complete record of the minimum set of their antenatal test results in their maternity notes.

Source guidance

Definitions of terms used in this quality statement

Minimum set of antenatal test results
Table 1 minimum set of tests for routine scheduled antenatal care
Investigation
Timing
Blood pressure
All routine appointments
Urine test for proteinuria
All routine appointments
Full blood count, blood group and rhesus D status
At booking or first scan if booking appointment was not face to face
Height, weight and body mass index
At booking or first scan if booking appointment was not face to face
Sickle cell and thalassaemia screen
At booking
Hepatitis B virus screen
At booking
HIV screen
At booking
Syphilis screen
At booking
Ultrasound scan to determine gestational age and detect multiple pregnancy
Between 11 weeks 2 days and 14 weeks 1 day
Screen for Down’s syndrome, Edward’s syndrome and Patau’s syndrome
Offer at booking
Ultrasound scan between 11 weeks 2 days and 14 weeks 1 day
Ultrasound screen for fetal anomalies
Offer at booking
Between 18 weeks 0 days and 20 weeks 6 days
Measure of symphysis fundal height
All routine appointments after 24 weeks 0 days
Full blood count, blood group and antibodies
At 28 weeks
Abdominal palpation to identify possible breech presentation
All routine appointments from 36 weeks 0 days
Note that women should be able to make an informed choice about whether to accept or decline each test, and notes should include a record of any tests offered and declined as well as the results of tests accepted. [NICE’s guideline on antenatal care, schedule of antenatal appointments]

Equality and diversity considerations

Maternity notes and the information within them should be accessible to all women, including women who do not speak or read English and those with additional needs such as physical, sensory or learning disabilities.
Women should be able to choose whether to have all the results of their antenatal tests documented in their maternity notes. This may be particularly important when information is sensitive (for example, positive screening results for HIV, hepatitis B virus and syphilis). Where a woman declines to have antenatal test results documented in her maternity notes, the results should instead be recorded within other medical notes. It is therefore appropriate that localities give special consideration to these groups of women within the measures. NICE’s guideline on pregnancy and complex social factors has recommendations about how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.

Risk assessment – body mass index

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

Quality statement

Pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered personalised advice from an appropriately trained person on healthy eating and physical activity.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence of local arrangements to offer pregnant women the option to have their body mass index calculated and recorded at the booking appointment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered personalised advice from an appropriately trained person on healthy eating and physical activity.
Process
a) Proportion of pregnant women accessing antenatal care whose body mass index is calculated and recorded at the booking appointment.
Numerator – the number in the denominator whose body mass index is recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
Data source: The NHS Digital Maternity Services Data Set collects data on the BMI of the mother at booking. Areas may wish to consider setting a local target that reflects expectations that some women may decide not to have their body mass index calculated.
b) Proportion of pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment who are offered personalised advice from an appropriately trained person on healthy eating and physical activity.
Numerator – the number in the denominator offered personalised advice from an appropriately trained person on healthy eating and physical activity.
Denominator – the number of pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment.
Data source: Local data collection. The NHS Digital Maternity Services Data Set collects data on the BMI of the mother at booking.
Outcome
Women with a body mass index of 30 kg/m2 or more feel confident to make decisions about healthy eating and physical activity during their pregnancy.
Data source: Local data collection, for example, local survey.

What the quality statement means for different audiences

Service providers ensure that systems are in place to offer pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice from an appropriately trained person on healthy eating and physical activity.
Healthcare professionals offer women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice on healthy eating and physical activity or, if they are not appropriately trained to do this, refer them to an appropriately trained person.
Commissioners ensure they commission services that offer pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice from an appropriately trained person on healthy eating and physical activity.
Pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered advice relevant to them from an appropriately trained person on healthy eating and physical activity.

Source guidance

Definitions of terms used in this quality statement

An appropriately trained person
Someone who can demonstrate expertise and competencies in weight management in pregnancy, including providing advice about nutrition and/or physical activity. This may include obstetricians, GPs, midwives, health visitors, nurses, dietitians, midwifery assistants, support workers and those working in weight management programmes (commercial or voluntary). [Expert opinion]

Equality and diversity considerations

The body mass index threshold may need adapting for different groups of pregnant women (for example, women from certain ethnic groups). A body mass index measure is considered unsuitable for use with those under 18.

Risk assessment – smoking cessation

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

Quality statement

Pregnant women who smoke are referred for evidence-based stop-smoking support at the booking appointment.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence of local arrangements that pregnant women have their smoking status recorded at the booking appointment.
Data source: NHS Digital’s Maternity Services Data Set collects data on smoking status at the booking appointment.
b) Evidence of local arrangements to ensure that pregnant women who smoke are referred for evidence-based stop-smoking support.
Data source: Local data collection.
c) Evidence of local arrangements to ensure that pregnant women who smoke and opt out of attending evidence-based stop smoking support receive follow-up.
Data source: Local data collection.
Process
a) Proportion of pregnant women accessing antenatal care whose smoking status is recorded at the booking appointment.
Numerator – the number in the denominator whose smoking status is recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
Data source: NHS Digital’s Maternity Services Data Set collects data on smoking status at the booking appointment.
b) Proportion of pregnant women who smoke who are referred for evidence-based stop-smoking support at the booking appointment.
Numerator – the number in the denominator who are referred for evidence-based stop-smoking support.
Denominator – the number of pregnant women who smoke and attend a booking appointment.
Data source: Local data collection.
c) Proportion of pregnant women who smoke and opt out of attending evidence-based stop-smoking support who receive follow-up.
Numerator – the number in the denominator who receive follow-up.
Denominator – the number of pregnant women who smoke and opt out of attending evidence-based stop-smoking support.
Data source: Local data collection.
Outcome
a) Quit rates for pregnant women.
Data source: Local data collection. NHS Digital’s statistics on NHS Stop Smoking Services in England includes quit rates for pregnant women who set a quit date.
b) Smoking rates in pregnancy.
Data source: NHS Digital Statistics on women's smoking status at time of delivery: England collects data on smoking status at the time of delivery.

What the quality statement means for different audiences

Service providers ensure that systems are in place to ensure that all pregnant women who smoke are referred for evidence-based stop-smoking support at their booking appointment.
Healthcare professionals refer all pregnant women who smoke for evidence-based stop-smoking support at their booking appointment.
Commissioners ensure they commission services that refer all pregnant women who smoke for evidence-based stop-smoking support at their booking appointment.
Pregnant women who smoke are referred for evidence-based stop-smoking support at their booking appointment.

Source guidance

Definitions of terms used in this quality statement

Referral for evidence-based stop-smoking support
An opt-out referral to receive stop-smoking support should be provided to all pregnant women who:
  • say they smoke or have stopped smoking in the past 2 weeks or
  • have a carbon monoxide reading of 4 parts per million(ppm) or above or
  • have previously been provided with an opt-out referral but have not yet engaged with stop-smoking support.
An opt-out referral to receive stop-smoking support should be first provided at the booking appointment and when appropriate throughout the period of antenatal care. The midwife may provide the pregnant woman with information about the risks to the unborn child of smoking when pregnant and the hazards of exposure to second-hand smoke for both mother and baby. [Adapted from NICE’s guideline on tobacco, recommendations 1.11.11, 1.18.2 and 1.19.3]
Evidence-based stop-smoking support
Interventions and support to stop smoking, regardless of how services are commissioned or set up.
Stop-smoking support for pregnant women should be intensive and ongoing throughout pregnancy and beyond. The professionals involved may include midwives who have been specially trained to help pregnant women who smoke to quit. [Adapted from NICE’s guideline on tobacco, recommendations 1.20.1, 1.23.3 and terms used in this guideline; stop-smoking support]

Risk assessment – gestational diabetes

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

Quality statement

Pregnant women are offered testing for gestational diabetes if they are identified as at risk of gestational diabetes at the booking appointment.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence of local arrangements to ensure that pregnant women have their risk factors for gestational diabetes identified and recorded at the booking appointment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women identified as at risk of gestational diabetes at the booking appointment are offered testing for gestational diabetes.
Data source: Local data collection.
Process
a) Proportion of pregnant women identified as at risk of gestational diabetes at the booking appointment who are offered testing for gestational diabetes.
Numerator – the number in the denominator offered testing for gestational diabetes.
Denominator – the number of pregnant women identified as at risk of gestational diabetes at the booking appointment.
Data source: Local data collection.
b) Proportion of pregnant women identified as at risk of gestational diabetes at the booking appointment who receive testing for gestational diabetes.
Numerator – the number of women in the denominator receiving testing for gestational diabetes.
Denominator – the number of pregnant women identified as at risk of gestational diabetes at the booking appointment.
Data source: Local data collection.
Outcome
Early identification of women with gestational diabetes.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place to offer pregnant women identified as at risk of gestational diabetes at the booking appointment testing for gestational diabetes.
Healthcare professionals offer pregnant women identified as at risk of gestational diabetes at the booking appointment testing for gestational diabetes.
Commissioners ensure they commission services that offer pregnant women identified as at risk of gestational diabetes at the booking appointment testing for gestational diabetes.
Pregnant women with a higher than normal chance of developing gestational diabetes (a type of diabetes that occurs during pregnancy) at the booking appointment are offered a test for gestational diabetes.

Source guidance

Definitions of terms used in this quality statement

At risk of gestational diabetes
Risk factors are:
  • body mass index above 30 kg/m2
  • previous macrosomic baby weighing 4.5 kg or more
  • previous gestational diabetes
  • family history of diabetes (first-degree relative with diabetes)
  • an ethnicity with a high prevalence of diabetes.
Women with any of these risk factors should be offered testing for gestational diabetes. [NICE’s guideline on diabetes in pregnancy, recommendation 1.2.2]
Testing for gestational diabetes
Use the 75-g 2-hour oral glucose tolerance test (OGTT) to test for gestational diabetes in women with risk factors.
Offer women who have had gestational diabetes in a previous pregnancy:
  • early self-monitoring of blood glucose or
  • a 75-g 2-hour OGTT as soon as possible after booking (whether in the first or second trimester), and a further 75-g 2-hour OGTT at 24–28 weeks if the results of the first OGTT are normal.
Offer women with any of the other risk factors for gestational diabetes a 75-g 2-hour OGTT at 24–28 weeks. [NICE’s guideline on diabetes in pregnancy, recommendations 1.2.5, 1.2.6 and 1.2.7]

Equality and diversity considerations

Any risk assessment for gestational diabetes should be corrected for ethnicity. Some ethnicities are risk factors for diabetes and people from these groups should be offered testing in accordance with the guidance.

Risk assessment – pre-eclampsia

This statement has been removed. For more details see update information in NICE's quality standard on antenatal care.

Risk assessment – venous thromboembolism

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

Quality statement

Pregnant women at risk of venous thromboembolism at the booking appointment are referred to an obstetrician for further management.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence of local arrangements to ensure that pregnant women have their risk of venous thromboembolism (VTE) assessed and recorded at the booking appointment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women at risk of VTE at the booking appointment are referred to an obstetrician for further management.
Data source: Local data collection.
Process
a) Proportion of pregnant women accessing antenatal care who have their risk of VTE assessed and recorded at the booking appointment.
Numerator – the number in the denominator who have their risk of VTE assessed and recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
Data source: Local data collection.
b) Proportion of pregnant women at risk of VTE at the booking appointment who are referred to an obstetrician for further management.
Numerator – the number in the denominator referred to an obstetrician for further management.
Denominator – the number of pregnant women at risk of VTE at the booking appointment.
Data source: Local data collection.
Outcome
Incidence of VTE in pregnant women.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place to refer pregnant women at risk of VTE at the booking appointment to an obstetrician for further management.
Healthcare professionals refer pregnant women at risk of VTE at the booking appointment to an obstetrician for further management.
Commissioners ensure they commission services which refer pregnant women at risk of VTE at the booking appointment to an obstetrician for further management.
Pregnant women who at the time of their booking appointment have a high or moderate chance of developing VTE (a blood clot) are referred to an obstetrician for support.

Source guidance

Antenatal care. NICE guideline NG201 (2021), recommendations 1.2.18 and 1.2.20

Definitions of terms used in this quality statement

At risk of VTE
High risk of VTE is defined as any previous VTE except a single event related to major surgery.
Intermediate risk of VTE is defined as any of the following:
  • hospital admission
  • single previous VTE related to major surgery
  • high-risk thrombophilia and no VTE
  • medical comorbidities, for example, cancer, heart failure, active lupus, inflammatory bowel disease, or inflammatory polyarthropathy, nephrotic syndrome, type 1 diabetes mellitus with nephropathy, sickle cell disease, current intravenous drug use
  • any surgical procedure, for example, appendicectomy
  • ovarian hyperstimulation syndrome (first trimester only).
Or 4 or more risk factors from the following list (or 3 risk factors from 28 weeks):
  • obesity (BMI above 30 kg/m2)
  • age above 35 years
  • parity 3 or more
  • smoking
  • gross varicose veins
  • current pre-eclampsia
  • immobility, for example, paraplegia, pelvic girdle pain with reduced mobility
  • family history of unprovoked or oestrogen-provoked VTE in first-degree relative
  • low-risk thrombophilia
  • multiple pregnancy
  • in vitro fertilisation or assisted reproductive technology
  • transient risk factors: dehydration/hyperemesis, current systemic infection, long-distance travel.

Risk assessment – high risk of venous thromboembolism

This statement has been merged with statement 8. For more details see update information in NICE's quality standard on antenatal care.

Screening – national fetal anomaly screening programmes

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

Quality statement

Pregnant women are offered fetal anomaly screening in accordance with current UK National Screening Committee programmes.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local NHS-commissioned services to ensure that all pregnant women are offered fetal anomaly screening in accordance with current UK National Screening Committee programmes.
Data source: Local data collection.
Process
a) Proportion of pregnant women booking before 21 weeks who are offered the NHS fetal anomaly screening programme at the booking appointment.
Numerator – the number in the denominator who are offered the NHS fetal anomaly screening programme.
Denominator – the number of pregnant women accessing antenatal care before 21 weeks.
Data source: Local data collection.
b) Proportion of pregnant women booking before 14 weeks 2 days that agreed to fetal anomaly screening who are offered an ultrasound scan to screen for Down’s syndrome, Edward’s syndrome and Patau’s syndrome to take place between 11 weeks 2 days and 14 weeks 1 day.
Numerator – the number in the denominator who are offered an ultrasound screening for Down’s syndrome, Edward’s syndrome and Patau’s syndrome to take place between 11 weeks 2 days and 14 weeks 1 day.
Denominator – the number of pregnant women booking before 14 weeks 2 days that agreed to fetal anomaly screening for Down’s syndrome, Edward’s syndrome and Patau’s syndrome.
Data source: Public Health England’s NHS Fetal Anomaly Screening Programme publishes data on first trimester combined screening for Down’s syndrome (T21), Edwards’ syndrome (T18) and Patau’s syndrome (T13).
c) Proportion of pregnant women booking before 21 weeks that agreed to fetal anomaly screening who are offered ultrasound screening for fetal anomalies to take place between 18 weeks 0 days and 20 weeks 6 days.
Numerator – the number in the denominator offered ultrasound screening for fetal anomalies to take place between 18 weeks 0 days and 20 weeks 6 days.
Denominator – the number of pregnant women booking before 21 weeks that agreed to fetal anomaly screening.
Data source: Public Health England’s NHS Fetal Anomaly Screening Programme publishes data on fetal anomaly ultrasound screening.
Outcome
a) Pregnant women feel they have made an informed decision about whether to undergo fetal anomaly screening.
Data source: Local data collection, for example, local survey.
b) Screening uptake rates.
Data source: Public Health England’s NHS Fetal Anomaly Screening Programme includes data on screening uptake rates.

What the quality statement means for different audiences

Service providers ensure that systems are in place to offer fetal anomaly screening to pregnant women in accordance with current UK National Screening Committee programmes.
Healthcare professionals offer fetal anomaly screening to pregnant women in accordance with current UK National Screening Committee programmes.
Commissioners ensure they commission services that offer fetal anomaly screening to pregnant women as part of NHS care, in accordance with current UK National Screening Committee programmes.
Pregnant women who access antenatal care before 14 weeks 2 days are offered ultrasound screening for Down’s syndrome, Edward’s syndrome and Patau’s syndrome.
Pregnant women who access antenatal care before 21 weeks are offered an ultrasound scan to screen for various conditions in their unborn baby.

Source guidance

Definitions of terms used in this quality statement

Fetal anomaly screening in accordance with current UK National Screening Committee programmes
The UK National Screening Committee recommends all eligible pregnant women in England are offered fetal anomaly screening. The NHS fetal anomaly screening programme has responsibility for implementing this policy.
The combined test uses maternal age, gestational age calculated from the crown-rump length measurement, nuchal translucency measurement, and two biochemical markers of pregnancy – associated plasma protein A and free beta human chorionic gonadotrophin hormone. The optimal time to perform the combined test is between 11 weeks 2 days and 14 weeks 1 day but a maternal blood specimen may be taken from 10 weeks onwards.
For women presenting too late for first trimester testing, the quadruple test (maternal age and four biochemical markers) window runs from 14 weeks 2 days to 20 weeks 0 days.
The fetal anomaly ultrasound scan should be offered to take place between 18 weeks 0 days and 20 weeks 6 days. [Adapted from Public Health England’s Fetal anomaly screening programme handbook and Fetal anomaly screening programme: standards]

Equality and diversity considerations

The offer and implications of screening should be understood by all women to enable them to make informed decisions. This will necessitate provision of information in an accessible format (particularly for women with physical, sensory or learning disabilities and women who do not speak or read English).

Fetal wellbeing – external cephalic version

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

Quality statement

Pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth are offered external cephalic version.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence of local arrangements to ensure that pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins) are referred for confirmatory ultrasound assessment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth are offered external cephalic version.
Data source: Local data collection.
Process
a) Proportion of pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins) who are referred for confirmatory ultrasound assessment.
Numerator – the number in the denominator referred for confirmatory ultrasound assessment.
Denominator – the number of pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins).
Data source: Local data collection.
b) Proportion of pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth who are offered external cephalic version.
Numerator – the number in the denominator offered external cephalic version.
Denominator – the number of pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth.
Data source: Local data collection.
Outcome
a) External cephalic version rates.
Data source: Local data collection.
b) Mode of delivery including:
  • rates of vaginal birth, emergency and elective caesarean section after successful external cephalic version
  • rates of vaginal birth, emergency and elective caesarean section after unsuccessful external cephalic version
  • rates of vaginal birth and emergency caesarean section after diagnosis of breech presentation in labour.
Data source: The NHS Digital Maternity Services Data Set collects data on delivery method.

What the quality statement means for different audiences

Service providers ensure that systems are in place to offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth external cephalic version.
Healthcare professionals offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth external cephalic version.
Commissioners ensure they commission services that offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth external cephalic version.
Pregnant women with a single baby in the breech position (bottom first with knees either flexed or extended) but with no other problems at 36 weeks or later in their pregnancy who prefer a vaginal birth are offered external cephalic version (a procedure to move the baby round to the head-down position), which includes first having an ultrasound scan to confirm the baby’s position.

Source guidance

Definitions of terms used in this quality statement

Pregnant women who prefer cephalic vaginal birth
For women with an uncomplicated singleton pregnancy with breech presentation confirmed after 36 weeks plus 0 days discuss the different options available and their benefits, risks and implications, including:
  • external cephalic version (to turn the baby from bottom to head down)
  • breech vaginal birth
  • elective caesarean birth.
[NICE’s guideline on antenatal care, recommendation 1.2.38]

Equality and diversity considerations

There may be some women whose breech presentation is not identified and who are not offered an external cephalic version.

Fetal wellbeing – membrane sweeping for prolonged pregnancy

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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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.
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.

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

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.

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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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.

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
Interventions and support to stop smoking, regardless of how services are commissioned or set up.
The following should be accessible to adults who smoke:
In November 2021, varenicline was unavailable in the UK. See the Medicines and Healthcare products Regulatory Agency (MHRA) alert on varenicline. [NICE’s guideline on tobacco, recommendation 1.12.2 and terms used in this guideline; stop-smoking support]

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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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.
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. The 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. The 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. NICE guideline NG122 (2019), 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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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 magnetic resonance imaging (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: Local data collection, for example, audit of patient records.
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.
Outcome
1 year survival rate for adults with lung cancer treated with curative intent.

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. NICE guideline NG122 (2019), recommendations 1.3.4, 1.3.18, 1.3.19, 1.3.22 to 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 to 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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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.
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. NICE guideline NG122 (2019), 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 to 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.

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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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.
b) 1 year survival rate for adults with non-small-cell lung cancer stage III or IV.

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

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.

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

Harm-reduction approach

Cutting down before stopping smoking

Smoking reduction

  • with the help of 1 or more medicinally licensed nicotine-containing products (the products may be used as long as needed to prevent relapse to previous levels of smoking)
  • without using medicinally licensed nicotine-containing products

Temporarily not smoking

  • with the help of 1 or more medicinally licensed nicotine-containing products
  • without using medicinally licensed nicotine-containing products

Harm-reduction approaches

Cutting down before stopping smoking

Smoking reduction

  • with the help of 1 or more medicinally licensed nicotine-containing products (the products may be used as long as needed to prevent relapse to previous levels of smoking)
  • without using medicinally licensed nicotine-containing products

Temporarily not smoking

  • with the help of 1 or more medicinally licensed nicotine-containing products
  • without using medicinally licensed nicotine-containing products
These recommendations are for anyone who is responsible for providing health and support services (including stop-smoking support) to people using acute, maternity or mental health services.
At the earliest opportunity, ask if any of the following people smoke:
  • partners of pregnant women
  • parents or carers of people using acute or mental health services
  • anyone else in the household.
If partners, parents, other household members and carers do not smoke, give them positive feedback if they are present.
If they do smoke:
  • encourage them to stop if they are present, and refer them to a hospital or local stop-smoking support using local arrangements if they want to stop or cut down their smoking
  • if they are not present, ask the person using services to suggest they contact stop-smoking support and provide contact details.
During contact with partners, parents, other household members and carers of people using acute, maternity and mental health services:
  • provide clear advice about the danger of smoking and secondhand smoke, including to pregnant women and babies – before and after birth
  • recommend not smoking around the patient, pregnant woman, mother or baby (this includes not smoking in the house).
Offer and, if the person agrees, arrange for them to receive behavioural support to stop smoking during either their current outpatient visit or their inpatient stay.
For people using secondary care services in the community, staff trained to provide behavioural support to stop smoking should offer and provide support. Other staff should offer and, if accepted, arrange a referral to local stop-smoking support.
These recommendations are for people who prescribe stop-smoking pharmacotherapies, and for pharmacists and health and social care professionals in acute, maternity and mental health services (including both inpatient and community mental health services).
Monitor people's use of prescribed medicines that are affected by smoking (or stopping smoking) for efficacy and adverse effects. Adjust the dosage as appropriate. Medicines that are affected include: clozapine, olanzapine, theophylline and warfarin. Refer to specific information for individual medicines, such as in the BNF or summaries of product characteristics in the Electronic Medicines Compendium.
Discuss with people who use secondary care and their carers that it might be possible to reduce the dose of some prescribed medicines when they stop smoking. Also advise them to seek medical advice if they notice any side effects from changing the amount they smoke.

Stopping smoking

These recommendations are for providers of secondary care and stop-smoking support, and managers of closed institutions and other services where smoking is not permitted.
Advise all staff who smoke to stop. Ensure systems are in place for staff who smoke to receive advice and guidance on how to stop in one go.
Encourage staff to use stop-smoking support to stop or cut down the amount they smoke. Provide contact details for community support if preferred.

Reducing smoking

These recommendations are for providers of secondary care, and managers of closed institutions and other services where smoking is not permitted.
For staff in secondary care and closed institutions who do not want, or are not ready, to stop smoking in one go:
Offer and provide behavioural support to help staff in secondary care and closed institutions not to smoke during working hours.
These recommendations are for directors of public health and those responsible for commissioning and managing tobacco cessation services.

Configuring and coordinating services

If local needs assessment shows that it is necessary, commission a range of services to help South Asian people stop using smokeless tobacco. Services should be in line with any existing local agreements or local enhanced service arrangements.
Provide services for South Asian users either within existing stop-smoking support or, for example, as:
  • Part of services offered within a range of healthcare and community settings (for example, GP or dental surgeries, community pharmacies and community centres – see the section on identifying people who use smokeless tobacco and offering referral).
  • A stand-alone service tailored to local needs (see the section on providing support to stop using smokeless tobacco). This might cater for specific groups such as South Asian women, speakers of a specific language or people who use a certain type of smokeless tobacco product. (The latter type of service could be named after the product, for example, it could be called a 'gutkha' cessation service).
Ensure local smokeless tobacco cessation services are coordinated and integrated with other tobacco control, prevention and cessation activities, as part of a comprehensive local tobacco control strategy. The services (and activities to promote them) should also be coordinated with, or linked to, national stop-smoking initiatives and other related national initiatives (for example, dental health campaigns).

Considering the needs of people who use smokeless tobacco

Ensure smokeless tobacco cessation services are part of a wider approach to addressing the health needs facing South Asian communities. They should be planned in partnership with relevant local voluntary and community organisations and user groups, and in consultation with local South Asian communities.
Ensure smokeless tobacco cessation services take into account the fact that some people who use smokeless tobacco products also smoke.
Ensure smokeless tobacco cessation services take into account the needs of people:
  • from different local South Asian communities (for example, by using staff with relevant language skills or translators, or by providing translated materials or resources in a non-written format)
  • who may be particularly concerned about confidentiality
  • who may not realise smokeless tobacco is harmful
  • who may not know help is available
  • who may find it difficult to use existing local services because of their social circumstances, gender, language, culture or lifestyle.
Offer pregnant women's partners who smoke help to stop. Use an intervention that comprises 3 or more elements and multiple contacts. Discuss with them which options to use – and in which order, taking into account:
  • their preferences
  • contraindications and the potential for adverse effects from stop-smoking pharmacotherapies
  • the likelihood that they will follow the course of treatment
  • their previous experience of stop-smoking aids.
  • do not favour one course of treatment over another; together, choose the one that seems most likely to succeed taking into account the above.
Include management of smoking in the care plan of people in closed institutions who smoke.
Develop a policy to ensure effective stop-smoking interventions are provided and promoted in prisons, military establishments and long-stay health centres, such as mental healthcare units. Use Department of Health and Social Care guidance to develop the policy.
Include NICE-recommended nicotine-containing products as options for sale in secondary care settings (for example, in hospital shops).
Ensure staff working in closed institutions recognise that some people see smoking as an integral part of their lives. Also ensure staff recognise the issues arising from being forced to stop, as opposed to doing this voluntarily.
Ensure staff recognise how the closed environment may restrict the techniques and coping mechanisms that people would normally use to stop smoking or reduce the amount they smoke. Provide the support needed for their circumstances. This includes prescribing or supplying medicinally licensed nicotine-containing products.
Ensure staff understand that if someone reduces the amount they smoke, or stops completely, this can affect their need for psychotropic and some other medications (see the summaries of product characteristics in the Electronic Medicines Compendium for further details). Ensure arrangements are in place to adjust their medication accordingly. See adjusting medicine dosages for people who have stopped smoking.
Do not allow staff with health and social care or custodial responsibilities to smoke during working hours in locations where the people in their care are not allowed to smoke.
Ensure all midwives are trained to assess and record people's smoking status and their readiness to quit. They should also:
  • know about the health risks of smoking and the benefits of quitting
  • understand why it can be difficult to stop
  • know about the treatments that can help people to quit, including NRT
  • know how to refer people who smoke to local services for treatment.
Ensure all healthcare and other professionals who work with pregnant women are trained in the same skills to support women to stop smoking, and to the same standard, as midwives. This includes:
  • GPs, practice nurses
  • health visitors
  • obstetricians
  • paediatricians
  • sonographers
  • midwives (including young people's lead midwives)
  • family nurses
  • those working in fertility clinics, dental facilities and community pharmacies
  • those working in youth and teenage pregnancy services, children's centres, social services and voluntary and community organisations.
Ensure that all healthcare and other professionals who work with pregnant women (see above):
  • understand the impact that smoking can have on a woman and her unborn child
  • understand the dangers of exposing a pregnant woman and her unborn child – and other children – to secondhand smoke.
Train all midwives who deliver intensive stop-smoking interventions (one-to-one or group support) to the same standard as stop-smoking advisers. The minimum standard for these interventions is set by the NCSCT. Also provide additional, specialised training and offer them ongoing support and training updates.
Ensure that midwives and specialist stop-smoking advisers who work with pregnant women:
  • know how to ask them questions in a way that encourages them to be open about their smoking
  • always recommend quitting rather than cutting down
  • have received accredited training in the use of carbon monoxide monitors.
Ensure training for health, dental health and allied professionals (for example, community pharmacists) covers:
  • the fact that smokeless tobacco may be used locally – and the need to keep abreast of statistics on local prevalence
  • the reasons why, and how, members of the South Asian community use smokeless tobacco (including the cultural context for its use)
  • the health risks associated with smokeless tobacco
  • the fact that some people of South Asian family origin may be less used to a preventive approach to health than the general population
  • the local names used for smokeless tobacco products, while emphasising the need to use the term 'smokeless tobacco' as well when talking to users about them.
Ensure training helps professionals to:
  • recognise the signs of smokeless tobacco use
  • know how to ask someone, in a sensitive and culturally aware manner, whether they use smokeless tobacco
  • provide information in a culturally sensitive way on the harm smokeless tobacco causes (this includes being able to challenge any perceived benefits – and the relative priority that users may place on these benefits)
  • deliver a brief intervention and refer people to tobacco cessation services if they want to quit.

Behavioural support

Scheduled meetings (face-to-face or virtual) between someone who smokes and a counsellor trained to provide stop-smoking support. Behavioural support can be provided either individually or in a group. Discussions may include information, practical advice about goal-setting, self-monitoring and dealing with the barriers to stopping smoking as well as encouragement. The support also includes anticipating and dealing with the challenges of stopping (see the NICE Pathway on behaviour change and the National Centre for Smoking Cessation and Training [NCSCT] Training Standard). 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 pharmacotherapies.

Brief interventions

A brief intervention (such as brief advice) involves discussion, negotiation or encouragement, with or without written or other support or follow up. But it may also involve a referral for further help. It is often carried out when the opportunity arises, typically taking no more than a few minutes for basic advice.

Brief intervention

A brief intervention (such as brief advice) involves discussion, negotiation or encouragement, with or without written or other support or follow up. But it may also involve a referral for further help. It is often carried out when the opportunity arises, typically taking no more than a few minutes for basic advice.

Cessation

Stopping the use of tobacco, smoked or smokeless. This includes stopping use of tobacco and moving on to pharmacotherapies (including NRT) or nicotine-containing e-cigarettes.

Closed institutions

Closed institutions are environments where people are detained or stay for a long time and where smoking is not permitted. These include secure mental health units, immigration removal centres, and custodial sites, as well as long-stay mental health units and military establishments.

E-cigarettes

Also called electronic cigarettes or vaping devices. A product that can be used for the inhalation of vapour through a mouthpiece. E-cigarettes can be disposable or refillable by means of a refill container and a tank, or can be rechargeable with single use cartridges. Products may be used to consume nicotine or used without nicotine (see nicotine-containing e-cigarettes).
Products that contain or could contain nicotine in the form of e-liquid are covered under the European Union's 2014 Tobacco Products Directive and need to be notified to the Medicines and Healthcare products Regulatory Agency (MHRA). Other devices such as disposable e-cigarettes that do not contain nicotine, and 0% nicotine e-liquids, are regulated under the General Product Safety Regulations (2005; definition informed by the MHRA's e-cigarettes: regulations for consumer products). E-cigarettes are not currently (November 2021) licensed medicines but are regulated by the Tobacco and Related Products Regulations (2016).

Harm reduction

Measures to reduce the illnesses and deaths caused by smoking tobacco among people who smoke and those around them. Some measures or products may reduce harm more than others. People who smoke and currently do not want, or are not ready, to stop in one go can reduce their harm by smoking less and abstaining from smoking temporarily. The benefits of harm reduction itself are uncertain, but it may mean people are more likely to stop smoking altogether in the future.

Medicinally licensed nicotine-containing products

Nicotine-containing products that have been given marketing authorisation by the Medicines and Healthcare products Regulatory Agency (MHRA). At the time of publication (November 2021), NRT products were the only type of medicinally licensed nicotine-containing product on the market. If any nicotine-containing e-cigarette were licensed by the MHRA and made commercially available, it would be included in this definition.

Nicotine-containing e-cigarettes

Nicotine-containing e-cigarettes are vaping devices filled with nicotine-containing e-liquid. These devices must be notified to the Medicines and Healthcare products Regulatory Agency (MHRA) and must meet the requirements of the European Union (2014) Tobacco Products Directive (definition informed by the MHRA's e-cigarettes: regulations for consumer products).
At the time of publication (November 2021), no nicotine-containing e-cigarettes were licensed as a medicine for stopping smoking by the MHRA and commercially available on the UK market. All nicotine-containing e-cigarettes in the UK that are not licensed as a medicine by the MHRA are regulated by the Tobacco and Related Products Regulations (2016), and cannot be marketed by the manufacturer for use for stopping smoking.

Nicotine-containing e-cigarette

Nicotine-containing e-cigarettes are vaping devices filled with nicotine-containing e-liquid. These devices must be notified to the Medicines and Healthcare products Regulatory Agency (MHRA) and must meet the requirements of the European Union (2014) Tobacco Products Directive (definition informed by the MHRA's e-cigarettes regulations for consumer products).
At the time of publication (November 2021), no nicotine-containing e-cigarettes were licensed as a medicine for stopping smoking by the MHRA and commercially available on the UK market. All nicotine-containing e-cigarettes in the UK that are not licensed as a medicine by the MHRA are regulated by the Tobacco and Related Products Regulations (2016), and cannot be marketed by the manufacturer for use for stopping smoking.

Nicotine-containing products

Products that contain nicotine but do not contain tobacco and so deliver nicotine without the harmful toxins found in tobacco. This currently includes NRT which has been medicinally licensed for smoking cessation by the Medicines and Healthcare products Regulatory Agency (MHRA) (see nicotine replacement therapy and nicotine-containing e-cigarettes). Currently there are no licensed nicotine-containing e-cigarettes on the market. Nicotine-containing e-cigarettes on general sale are regulated under the Tobacco and Related Products Regulations (2016) by the MHRA. For further details, see the MHRA website.

Nicotine replacement therapy (NRT)

Products medicinally licensed for use as a stop-smoking aid and for harm reduction, as outlined in the BNF. They include transdermal patches, gum, inhalation cartridges, sublingual tablets, lozenges, mouth spray and nasal spray.

Nicotine replacement therapy (NRT)

Products medicinally licensed for use as a stop-smoking aid and for harm reduction, as outlined in the British national formulary. They include transdermal patches, gum, inhalation cartridges, sublingual tablets, lozenges, mouth spray and nasal spray.

Pharmacotherapy

This covers medication licensed for smoking cessation such as varenicline or bupropion, as well as nicotine replacement therapy. In November 2021, varenicline was unavailable in the UK. See the MHRA alert on varenicline.

Pharmacotherapies

This covers medication licensed for smoking cessation such as varenicline or bupropion, as well as nicotine replacement therapy. In November 2021, varenicline was unavailable in the UK. See the MHRA alert on varenicline.

Schools

This term is used to refer to:
  • 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.

School

This term is used to refer to:
  • 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.

Secondary care

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 in hospitals, maternity units, outpatient clinics and in the community.

Self-help materials

Any manual or structured programme, in written or digital format, that someone can use to try to stop smoking or reduce the amount they smoke. These can be used without the help of healthcare professionals, stop-smoking advisers or group support. They can be aimed at anyone who smokes, particular populations (for example, certain ages or ethnic groups), or may be tailored to individual need.

Smokeless tobacco

Any product containing tobacco that is placed in the mouth or nose and not burned and which is typically used in England by people of South Asian family origin. It does not include products that are sucked, like 'snus' or similar oral snuff products. (As defined in the European Union (2014) Tobacco Product Directive).
The types used vary across the country but they can be divided into 3 main categories, based on their ingredients (Stanfill et al. 2010):
  • Tobacco with or without flavourants: misri India tobacco (powdered) and qimam (kiman).
  • Tobacco with various alkaline modifiers: khaini, naswar (niswar, nass) and gul.
  • Tobacco with slaked lime as an alkaline modifier and areca nut: gutkha, zarda, mawa, manipuri and betel quid (with tobacco).

Specialist tobacco cessation services

Evidence-based services that offer support to help people stop smoking or using smokeless tobacco. In England, these are generally referred to as 'stop-smoking support or services' or 'smoking cessation services' because they normally focus on people who smoke tobacco. But a service might brand itself as a generic tobacco cessation or tobacco dependence service, to emphasise a focus on more than 1 form of tobacco.

Stopping in one go

The standard approach in most stop-smoking support. The person makes a commitment to stop smoking on or before a particular date (the quit date). This may or may not involve the use of pharmacotherapies or nicotine-containing e-cigarettes before the quit date and for some time afterwards, depending on the person's needs.

Stop in one go

The standard approach in most stop-smoking support. The person makes a commitment to stop smoking on or before a particular date (the quit date). This may or may not involve the use of pharmacotherapies or nicotine-containing e-cigarettes before the quit date and for a period of time afterwards, depending on the person's needs.

Temporary abstinence

Stopping smoking with or without medication for a particular event or series of events, in a particular location, for specific time periods (for example, while at work, during long-haul flights or during a hospital stay), or for the foreseeable future. (The latter might include, for example, abstinence while serving a prison sentence or while detained in a secure mental health unit.)

Glossary

(inhaling more deeply or smoking more of each cigarette to compensate for smoking fewer cigarettes)
(refers to the incidence of minor and major side effects associated with nicotine-containing products)
(air that is free of tobacco smoke. E-cigarettes are not covered by smokefree legislation)
(people with ancestral links to countries in southern Asia, including Bangladesh, India, Nepal, Pakistan or Sri Lanka)
(interventions and support to stop smoking, regardless of how services are commissioned or set up)
(these provide proactive or reactive advice, encouragement, counselling and support by phone to anyone who smokes who wants to quit, or who has recently quit)
(these provide proactive or reactive advice, encouragement, counselling and support by phone to anyone who smokes who wants to quit, or who has recently quit)

Paths in this pathway

Pathway created: May 2011 Last updated: November 2021

© NICE 2022. All rights reserved. Subject to Notice of rights.

Recently viewed