Tobacco: preventing
uptake, promoting quitting
and treating dependence
NICE guideline
Published: 30 November 2021
www.nice.org.uk/guidance/ng209
? NICE 2023. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
conditions#notice-of-rights). Last updated 16 January 2023
Your responsibility
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.
All problems (adverse events) related to a medicine or medical device used for treatment
or in a procedure should be reported to the Medicines and Healthcare products Regulatory
Agency using the Yellow Card Scheme.
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.
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Contents
Overview .................................................................................................................................... 6
Who is it for? ......................................................................................................................................... 6
Recommendations on preventing uptake ............................................................................... 8
1.1 Organising and planning national, regional or local mass-media campaigns ........................... 9
1.2 Campaign strategies to prevent uptake and denormalise tobacco use ................................... 10
1.3 Helping retailers avoid illegal tobacco sales ................................................................................ 11
1.4 Coordinated approach to school-based interventions ............................................................... 12
1.5 Whole-school or organisation-wide smokefree policies ............................................................ 12
1.6 Adult-led interventions in schools ................................................................................................ 13
1.7 Peer-led interventions in schools .................................................................................................. 15
Recommendations on promoting quitting ............................................................................... 16
1.8 Using medicinally licensed nicotine-containing products .......................................................... 17
1.9 Promoting stop-smoking support ................................................................................................. 18
1.10 Promoting support for people to stop using smokeless tobacco ............................................ 20
Recommendations on treating tobacco dependence ............................................................ 22
1.11 Identifying and quantifying people''s smoking ............................................................................ 24
1.12 Stop-smoking interventions ......................................................................................................... 26
1.13 Support to stop smoking in primary care and community settings ......................................... 32
1.14 Support to stop smoking in secondary care services ............................................................... 32
1.15 Supporting people who do not want, or are not ready, to stop smoking in one go to
reduce their harm from smoking ........................................................................................................ 39
1.16 Stopping use of smokeless tobacco ........................................................................................... 43
1.17 Adherence and relapse prevention ............................................................................................. 48
Recommendations on treating tobacco dependence in pregnant women .......................... 51
1.18 Identifying pregnant women who smoke and referring them for stop-smoking support ...... 51
1.19 Following up women who have been referred for stop smoking support ............................... 53
1.20 Providing support to stop smoking ............................................................................................ 54
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Recommendations on policy, commissioning and training ................................................... 59
1.21 Policy .............................................................................................................................................. 60
1.22 Commissioning and designing services ..................................................................................... 63
1.23 Training .......................................................................................................................................... 68
Terms used in this guideline ..................................................................................................... 74
Allen Carr''s in-person group seminar ................................................................................................. 74
Behavioural support ............................................................................................................................. 74
Cessation .............................................................................................................................................. 74
Closed institutions ............................................................................................................................... 75
Compensatory smoking ....................................................................................................................... 75
E-cigarettes .......................................................................................................................................... 75
Harm reduction ..................................................................................................................................... 75
Medicinally licensed nicotine-containing products .......................................................................... 76
Nicotine-containing products ............................................................................................................. 76
Nicotine-containing e-cigarettes ........................................................................................................ 76
Nicotine replacement therapy ............................................................................................................ 76
Pharmacotherapies .............................................................................................................................. 77
Safety .................................................................................................................................................... 77
Schools .................................................................................................................................................. 77
Secondary care .................................................................................................................................... 77
Self-help materials ............................................................................................................................... 77
Smokefree ............................................................................................................................................. 78
Smokeless tobacco .............................................................................................................................. 78
South Asian family origin ..................................................................................................................... 78
Specialist tobacco cessation services ............................................................................................... 78
Stop in one go ...................................................................................................................................... 79
Stop-smoking support ......................................................................................................................... 79
Telephone quitlines .............................................................................................................................. 79
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Temporary abstinence ......................................................................................................................... 79
Under-served groups ........................................................................................................................... 79
Recommendations for research ............................................................................................... 80
Key recommendations for research ................................................................................................... 80
Other recommendations for research ................................................................................................ 82
Rationale and impact ................................................................................................................. 86
Adult-led interventions in schools ...................................................................................................... 86
Stop-smoking interventions ................................................................................................................ 87
Advice on nicotine-containing e-cigarettes ...................................................................................... 90
Stop-smoking support in mental health services ............................................................................. 92
Nicotine-containing e-cigarettes for harm reduction ....................................................................... 93
Supporting people trying to stop smoking ........................................................................................ 94
Reviewing the approach for people trying to stop smoking, cutting down or stopping
temporarily ............................................................................................................................................ 95
Identifying pregnant women who smoke and referring them for stop-smoking support ............. 95
Nicotine replacement therapy and other pharmacological support ............................................... 97
Incentives to stop smoking ................................................................................................................. 98
Commissioning and designing services ............................................................................................. 99
Stop-smoking support in secondary care ......................................................................................... 100
Context ....................................................................................................................................... 102
Finding more information and committee details ................................................................... 104
Update information ................................................................................................................... 105
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This guideline replaces PH5, PH14, PH23, PH26, PH39, PH45, PH48 and NG92.
This guideline is the basis of QS17, QS82, QS22 and QS207.
Overview
This guideline covers support to stop smoking for everyone aged 12 and over, and help to
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 guideline brings together and updates all NICE''s previous guidelines on
using tobacco, including smokeless tobacco. It covers nicotine replacement therapy and
e-cigarettes to help people stop smoking or reduce their harm from smoking. It does not
cover using tobacco products such as ''heat not burn'' tobacco.
In August 2022, varenicline was unavailable in the UK. See the MHRA alert on varenicline.
Who is it for?
? Commissioners and providers of stop-smoking interventions and support, including
those in the voluntary and community sectors
? Commissioners and providers of interventions and support for preventing uptake of
smoking
? Health and social care professionals, including clinical leads in secondary care
services and managers of clinical services
? People working in local authorities, education and the wider public, private, voluntary
and community sectors
? Those commissioning, planning and delivering mass-media campaigns
? People with a remit to improve the health and wellbeing of children and young people
aged 24 and under; this includes those working in the NHS, local authorities and
tobacco control alliances
? Retailers of tobacco products
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? Employers, estate managers and other managers
? Employee and trade union representatives
It may also be relevant for:
? Researchers and policy makers
? Manufacturers and retailers of medicinally licensed nicotine-containing products and
nicotine-containing e-cigarettes
? Members of the public, including:
－ children, young people, their parents and carers
－ people using health and social care services, and their families and carers
－ women who are pregnant or planning a pregnancy, or who have a child aged up to
12 months, and their families and carers
－ people over 16 who smoke and are in paid or voluntary employment
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Recommendations on preventing uptake
People have the right to be involved in discussions and make informed decisions
about their care, as described in NICE''s information on making decisions about 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.
This guideline should be read alongside NICE''s guidelines on patient experience in
adult NHS services and babies, children and young people''s experience of
healthcare, which have guidance on giving information to people and discussing their
views and preferences.
In this guideline, we use the following terms for age groups:
? children: aged 5 to 11
? young people: aged 12 to 17
? young adults: aged 18 to 24
? adults: aged 18 and over.
Unless otherwise stated, the recommendations on preventing uptake are for children
and those aged 24 and under.
At the time of publication (November 2021), no nicotine-containing e-cigarettes were
licensed as a medicine for stopping smoking by the Medicines and Healthcare
products Regulatory Agency (MHRA) and commercially available in 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.
These recommendations aim to prevent children, young people and young adults from
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taking up smoking. They cover anti-smoking mass-media and digital campaigns, measures
to prevent tobacco being sold to and bought for children and young people, and
prevention interventions in educational settings.
1.1 Organising and planning national, regional or
local mass-media campaigns
These recommendations are for commissioners and organisers of mass-media campaigns.
1.1.1 Develop national, regional or local mass-media campaigns to prevent the
uptake of smoking among young people under 18. Work in partnership
with: the NHS, national, regional and local government and non-
governmental organisations, children and young people, media
professionals, healthcare professionals, public relations agencies and
local anti-tobacco activists. [2008]
1.1.2 Integrate regional and local campaigns to prevent smoking in children
and young people with any national communications strategy to tackle
tobacco use. [2008]
1.1.3 Think about targeting campaigns towards groups that epidemiological
data identify as having higher than average or stagnant rates of smoking.
Base the campaigns on research that identifies and helps to understand
the target audiences. [2008]
1.1.4 Base campaign messages on strategic research and qualitative before-
and-after testing with the target audiences. Repeat the messages in
various ways and regularly update them to keep the audience''s attention.
[2008, amended 2021]
1.1.5 Use a range of media channels to get unpaid press coverage and
generate as much publicity as possible. Reach specific audiences by:
? using regional and local channels
? using the full range of media used by children and young people. [2008,
amended 2021]
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1.1.6 Share effective practice in campaigns to prevent smoking in children and
young people, including effective local and regional media messages,
locally, regionally and nationally. [2008]
1.1.7 Run campaigns to prevent smoking in children and young people for 3 to
5 years. [2008]
1.1.8 Use process and outcome measures to ensure campaigns are being
delivered correctly and effectively. For recommendations on the
principles of evaluation, see NICE''s guideline on behaviour change:
general approaches. [2008]
1.2 Campaign strategies to prevent uptake and
denormalise tobacco use
These recommendations are for local authorities, trading standards bodies, organisers and
planners of national, regional and local mass-media campaigns, and commissioners and
planners.
1.2.1 Assess whether an advocacy campaign is needed to support policy
related to illegal tobacco sales. [2008, amended 2021]
1.2.2 If an advocacy campaign is needed, base it on good practice. Use a
range of strategies to reduce the attractiveness of tobacco and
contribute to changing society''s attitude towards tobacco use, so that
smoking is not considered the norm by any group. This could include:
? generating news by writing articles, commissioning newsworthy research and
issuing press releases
? using posters, brochures and other materials
? using digital media. [2008]
1.2.3 As part of an advocacy campaign, provide a clear, published statement
on how to deal with underage tobacco sales. [2008]
1.2.4 Do not develop or deliver mass-media or access-restriction campaigns in
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conjunction with (or supported by) tobacco organisations. Actively
discourage use of enforcement and related campaigns developed by
tobacco organisations. [2008]
1.3 Helping retailers avoid illegal tobacco sales
These recommendations are for local authorities and trading standards bodies.
1.3.1 Provide retailers with training and guidance on how to avoid illegal sales.
This includes encouraging them to:
? ask for proof of age from anyone who appears younger than 18 who attempts
to buy cigarettes, and get it verified (examples of proof include a passport or
driving licence, or cards bearing the nationally accredited ''PASS'' hologram)
? inform Trading Standards of each tobacco sale refused on the grounds of age.
[2008]
1.3.2 Make it as difficult as possible for young people under 18 to get
cigarettes and other tobacco products. In particular, exercise a statutory
duty under the Children and Young Persons (Protection from Tobacco)
Act (1991) to prevent underage sales by:
? prosecuting retailers who persistently break the law
? 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. [2008]
1.3.3 Work with other agencies to:
? identify areas where underage tobacco sales are a particular problem
? improve inspection and enforcement activities related to illegal tobacco sales.
[2008]
1.3.4 Run campaigns for retailers to publicise legislation prohibiting underage
tobacco sales. These could include:
? details of possible fines that retailers can face
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? details of where tobacco is being sold illegally
? successful local prosecutions
? health information. [2008]
1.3.5 Ensure efforts to reduce illegal tobacco sales by retailers are sustained.
[2008]
1.4 Coordinated approach to school-based
interventions
This recommendation is for schools, commissioners, local authorities, careers services or
integrated youth support services, and local tobacco control alliances.
1.4.1 Ensure smoking prevention interventions in schools and other
educational establishments are:
? part of a local tobacco control strategy
? evidence-based
? linked to the school or educational establishment''s smokefree policy
? consistent with regional and national tobacco control strategies
? integrated into the curriculum. [2010]
See also NICE''s guideline on behaviour change: general approaches.
1.5 Whole-school or organisation-wide smokefree
policies
These recommendations are for everyone working in and with primary and secondary
schools and further education colleges.
1.5.1 Develop a whole-school or organisation-wide smokefree policy in
consultation with young people and staff:
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? Include smoking prevention activities (led by adults or young people).
? Include staff training and development.
? Take account of children and young people''s cultural, special educational or
physical needs. (For example, by providing material in alternative formats such
as pictures, large print, Braille, audio and video.) [2010]
1.5.2 Ensure the policy forms part of the wider strategy on wellbeing,
relationships education, relationships and sex education (RSE), health
education, drug education and behaviour. [2010]
1.5.3 Apply the policy to everyone using the premises (grounds as well as
buildings), for any purpose, at any time. Do not allow any areas in the
grounds to be designated for smoking (with the exception of caretakers''
homes, as specified by law). [2010]
1.5.4 Widely publicise the policy and ensure it is easily accessible so that
everyone using the premises is aware of its content. (This includes
making a printed version available.) [2010]
See also NICE''s guidelines on alcohol interventions in secondary and further education
and social, emotional and mental wellbeing in primary and secondary education.
1.6 Adult-led interventions in schools
These recommendations are for everyone working in and with primary and secondary
schools and further education colleges.
1.6.1 Integrate information about the health effects of tobacco use, as well as
the legal, economic and social aspects of smoking, into the curriculum.
For example, classroom discussions about tobacco could be relevant
when teaching subjects such as biology, chemistry, citizenship,
geography, mathematics and media studies. [2010]
1.6.2 Include accurate information about smoking in the curriculum, including
its prevalence and its consequences. Tobacco use by adults and peers
should be discussed and challenged. Aim to:
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? develop decision-making skills through active learning techniques
? include strategies for enhancing self-esteem and resisting the pressure to
smoke from the media, family members, peers and the tobacco industry.
[2010]
1.6.3 As part of the curriculum on tobacco, alcohol and drug misuse,
discourage children, young people and young adults who do not smoke
from experimenting with or regularly using e-cigarettes. Talk about
e-cigarettes separately from tobacco products. [2021]
1.6.4 When discussing e-cigarettes, make it clear why children, young people
and young adults who do not smoke should avoid e-cigarettes to avoid
inadvertently making them desirable. [2021]
1.6.5 Provide additional ''booster'' activities to support classroom education on
tobacco until school leaving age. Activities might include school health
fairs and guest speakers. [2010]
1.6.6 Ensure smoking prevention interventions are delivered by teachers and
higher-level teaching assistants who are both credible and competent in
the subject, or by external experts. The latter should be trained to work
with children and young people on tobacco issues. Interventions should
be:
? entertaining, factual and interactive
? tailored to age and ability
? sensitive to family origin, culture and gender
? non-judgemental. [2010]
1.6.7 Involve children and young people in schools in the design of
interventions to prevent the uptake of smoking. [2010]
1.6.8 Encourage parents and carers to become involved. For example, let them
know about classwork or ask them to help with homework assignments.
[2010]
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For a short explanation of why the committee made the 2021 recommendations and
how they might affect practice, see the rationale and impact section on adult-led
interventions in schools.
Full details of the evidence and the committee''s discussion are in evidence review F
and G: e-cigarettes and young people.
1.7 Peer-led interventions in schools
This recommendation is for everyone working in and with secondary schools and further
education colleges.
1.7.1 Consider evidence-based, peer-led interventions aimed at preventing
the uptake of smoking. They should:
? link to relevant parts of the curriculum
? be delivered both in class and informally, outside the classroom
? be led by young people nominated by the students themselves (the peer
leaders could be the same age or older)
? ensure peer leaders receive support from adults who have the appropriate
expertise during the course of the programme
? ensure young people can consider and, if necessary, challenge peer and family
norms on smoking, discuss the risks associated with it and the benefits of not
smoking. [2010, amended 2021]
See also NICE''s guideline on alcohol interventions in secondary and further education.
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Recommendations on promoting quitting
People have the right to be involved in discussions and make informed decisions
about their care, as described in NICE''s information on making decisions about 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.
This guideline should be read alongside NICE''s guidelines on patient experience in
adult NHS services and babies, children and young people''s experience of
healthcare, which have guidance on giving information to people and discussing their
views and preferences.
In this guideline, we use the following terms for age groups:
? children: aged 5 to 11
? young people: aged 12 to 17
? young adults: aged 18 to 24
? adults: aged 18 and over.
At the time of publication (November 2021), no nicotine-containing e-cigarettes were
licensed as a medicine for stopping smoking by the Medicines and Healthcare
products Regulatory Agency (MHRA) and commercially available in 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.
These recommendations promote options to help people stop smoking or using smokeless
tobacco or, if they do not want or are not ready to stop in one go, to reduce their harm.
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1.8 Using medicinally licensed nicotine-containing
products
Raising awareness
These recommendations are for people working in public health, and others with tobacco
control and providing advice about harm reduction as part of their remit.
1.8.1 Raise public awareness of the harm caused by smoking and secondhand
smoke. Make it clear that smoking causes a range of diseases and
conditions including cancer, chronic obstructive pulmonary disease and
cardiovascular disease. [2013]
1.8.2 Provide information on how people who smoke can reduce the risk of
illness and death (to themselves and others) by using 1 or more
medicinally licensed nicotine-containing products. Explain that they
could be used as a partial or complete substitute for tobacco, either
temporarily or in the long term. [2013]
1.8.3 Provide the following information about nicotine:
? smoking is highly addictive mainly because it delivers nicotine very quickly to
the brain and this makes stopping smoking difficult
? most smoking-related health problems are caused by other components in
tobacco smoke, not by the nicotine
? nicotine levels in medicinally licensed nicotine-containing products are much
lower than in tobacco, and the way these products deliver nicotine makes them
less addictive than smoking. [2013, amended 2021]
1.8.4 Provide the following information about the effectiveness and safety of
medicinally licensed nicotine-containing products:
? any risks from using medicinally licensed nicotine-containing products are
much lower than those of smoking; nicotine replacement therapy (NRT)
products have been demonstrated in trials to be safe to use for at least 5 years
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? lifetime use of medicinally licensed nicotine-containing products is likely to be
considerably less harmful than smoking. [2013]
1.8.5 Provide information on using medicinally licensed nicotine-containing
products, including:
? what forms they take
? how to use them effectively when trying to stop or cut down smoking
? long-term use to reduce the risk of relapsing
? where to get them
? the cost compared with smoking. [2013]
For recommendations on what information to provide about nicotine-containing
e-cigarettes, see the section on advice on nicotine-containing e-cigarettes.
Point-of-sale promotion
These recommendations are for manufacturers and retailers of medicinally licensed
nicotine-containing products, including tobacco retailers.
1.8.6 Encourage people who smoke to consider stopping or, if they do not
want or are not ready to stop in one go, to consider the harm-reduction
approaches outlined in box 1. [2013]
1.9 Promoting stop-smoking support
Developers of communications strategies
1.9.1 Coordinate communications strategies to support the delivery of stop-
smoking support, telephone quitlines, school-based interventions,
tobacco control policy changes and any other activities designed to help
people to stop smoking. [2018]
1.9.2 Develop and deliver communications strategies about stopping smoking
in partnership with the NHS, national, regional and local government and
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non-governmental organisations. The strategies should:
? Use the best available evidence of effectiveness, such as Cochrane reviews.
? Be developed and evaluated using audience research.
? Use ''why to'' and ''how to'' stop messages that are non-judgemental, empathetic
and respectful. For example, use testimonials from people who smoke or used
to smoke.
? Involve community pharmacies in local campaigns and maintain links with other
professional groups such as dentists, fire services and voluntary groups.
? Ensure campaigns are sufficiently extensive and sustained to have a
reasonable chance of success.
? Think about targeting and tailoring campaigns towards groups that
epidemiological data identify as having higher than average or stagnant rates
of smoking, to address inequalities. [2018, amended 2021]
Schools
1.9.3 Make information on local stop-smoking support easily available to staff
and students. Include details on the type of help available and when,
where and how to access the services. [2010]
Employers
1.9.4 Make information on local stop-smoking support easily available at work.
Include details on the type of help available and when, where and how to
access the services. Publicise these interventions. [2007]
1.9.5 Be responsive to individual needs and preferences of employees. If
feasible, and if there is sufficient demand, provide on-site stop-smoking
support. [2007]
1.9.6 Allow staff to attend stop-smoking support during working hours without
loss of pay. [2007]
1.9.7 Negotiate a smokefree workplace policy with employees or their
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representatives. This should:
? State whether or not smoking breaks may be taken during working hours and,
if so, where, how often and for how long.
? Include a stop-smoking policy developed in collaboration with staff and their
representatives.
? Direct people who wish to stop smoking to local stop-smoking support. [2018]
Employees and their representatives
1.9.8 Encourage employers to provide advice, guidance and support to help
employees who want to stop smoking. [2007]
1.10 Promoting support for people to stop using
smokeless tobacco
These recommendations are for public sector, voluntary and community organisations,
health and social care professionals and faith groups. They are particularly relevant to
South Asian communities in areas of identified need.
1.10.1 Work in partnership with existing community initiatives to raise
awareness of local smokeless tobacco cessation services and how to
access them. Ensure any material used to raise awareness of the
services:
? Uses the names that the smokeless tobacco products are known by locally, as
well as the term ''smokeless tobacco''.
? Gives information about the health risks associated with smokeless tobacco
and the availability of services to help people quit.
? Challenges the perceived benefits – and the relative priority that users may
place on these benefits (compared with the health risks). For example, some
people think smokeless tobacco is an appropriate way to ease indigestion or
relieve dental pain, or help freshen the breath.
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? Addresses the needs of people whose first language is not English (by
providing translations).
? Addresses a range of communication needs by providing material in alternative
formats, for example pictures, large print, Braille, audio and video.
? Includes information for specific South Asian subgroups (for example, older
Bangladeshi women) who are known to have high rates of smokeless tobacco
use.
? Discusses the concept of addiction in a way that is sensitive to culture and
religion (for example, it may be better to refer to users as having developed a
''habit'', rather than being ''addicted'').
? Does not stigmatise users of smokeless tobacco products within their own
community, or in the eyes of the general community. [2012]
1.10.2 Use existing local South Asian information networks (including culturally
specific TV and radio channels), and traditional sources of health advice
within South Asian communities to provide information on smokeless
tobacco. [2012]
1.10.3 Use venues and events that members of local South Asian communities
frequent to publicise, provide or consult on cessation services with them.
(Examples include educational establishments and premises where
prayer groups or cultural events are held.) [2012]
1.10.4 Raise awareness among those who work with children and young people
about smokeless tobacco use. This includes:
? providing teachers with information on the harm that smokeless tobacco
causes and that also challenges the perceived benefits – and the priority that
users may place on these perceived benefits
? encouraging teachers to discuss with their students the reasons why people
use smokeless tobacco; this could take place as part of drug education, or
within any other relevant part of the curriculum. [2012]
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Recommendations on treating tobacco
dependence
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People have the right to be involved in discussions and make informed decisions
about their care, as described in NICE''s information on making decisions about 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.
This guideline should be read alongside NICE''s guidelines on patient experience in
adult NHS services and babies, children and young people''s experience of
healthcare, which have guidance on giving information to people and discussing their
views and preferences.
In this guideline, we use the following terms for age groups:
? children: aged 5 to 11
? young people: aged 12 to 17
? young adults: aged 18 to 24
? adults: aged 18 and over.
Unless otherwise stated, the recommendations on treating tobacco dependence are
for people over the age of 12 who want to stop smoking or reduce harm from
smoking.
At the time of publication (November 2021), no nicotine-containing e-cigarettes were
licensed as a medicine for stopping smoking by the Medicines and Healthcare
products Regulatory Agency (MHRA) and commercially available in 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.
These recommendations aim to help people aged 12 or over (unless otherwise stated) to
stop smoking or, if they do not want or are not ready to stop in one go, to reduce their
harm from smoking. They cover interventions and services delivered in a range of settings,
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including NHS primary and secondary care, and emphasise the importance of targeting
vulnerable groups who find giving up smoking hard or who smoke a lot. Pregnant women
are mainly covered in the section on treating tobacco dependence in pregnant women.
1.11 Identifying and quantifying people''s smoking
Identifying people who smoke
These recommendations are for health and social care professionals and those providing
stop-smoking support or advice (for recommendations about pregnant women see the
section on identifying pregnant women who smoke and referring them for stop-smoking
support).
1.11.1 At every opportunity, ask people if they smoke or have recently stopped
smoking. [2018]
1.11.2 If they smoke, advise them to stop smoking in a way that is sensitive to
their preferences and needs, and advise them that stopping smoking in
one go is the best approach. Explain how stop-smoking support can
help. [2018]
1.11.3 Discuss any stop-smoking aids the person has used before, including
personally purchased nicotine-containing products. [2018]
1.11.4 Offer advice on using nicotine-containing products on general sale,
including over-the-counter nicotine replacement therapy (NRT) and
nicotine-containing e-cigarettes. [2018]
1.11.5 If someone does not want, or is not ready, to stop smoking in one go:
? find out about the person''s smoking behaviour and level of nicotine
dependence by asking how many cigarettes they smoke – and how soon after
waking
? make sure they understand that stopping smoking reduces the risks of
developing smoking-related illnesses or worsening conditions affected by
smoking
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? ask them to think about adopting a harm-reduction approach (see the section
on supporting people who do not want, or are not ready, to stop smoking in
one go)
? encourage them to seek help to stop smoking completely in the future
? leave the offer of help open and offer support again the next time they are in
contact. [2013]
1.11.6 Record smoking status and all actions, discussions and decisions related
to advice, referrals or interventions about stopping smoking. [2018]
1.11.7 Ask about their smoking status at the next available opportunity. [2013]
Identifying smoking among carers, family and other household
members
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.
1.11.8 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. [2013]
1.11.9 If partners, parents, other household members and carers do not smoke,
give them positive feedback if they are present. [2013]
1.11.10 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. [2013]
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1.11.11 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). [2010]
1.12 Stop-smoking interventions
These recommendations are for people providing stop-smoking support or advice. For
training requirements see the National Centre for Smoking Cessation and Training
(NCSCT) standard for training in smoking cessation treatments.
For recommendations on digital and mobile health interventions for stopping smoking, see
NICE''s guideline on behaviour change: digital and mobile health interventions.
See recommendation 1.14.23 for advice on people''s use of prescribed medicines that are
affected by smoking (or stopping smoking).
1.12.1 Tell people who smoke that a range of interventions is available to help
them stop smoking. Explain how to access them and refer people to
stop-smoking support if appropriate. [2021]
1.12.2 Ensure the following are accessible to adults who smoke:
? behavioural interventions:
－ behavioural support (individual and group)
－ very brief advice
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? medicinally licensed products:
－ bupropion (see BNF information on bupropion hydrochloride)
－ nicotine replacement therapy – short and long acting
－ varenicline (see NICE''s technology appraisal guidance on varenicline for
smoking cessation and the BNF information on varenicline)
? nicotine-containing e-cigarettes
? Allen Carr''s Easyway in-person group seminar.
In August 2022, varenicline was unavailable in the UK. See the MHRA alert on
varenicline. [2021, amended 2022]
1.12.3 Consider NRT for young people aged 12 and over who are smoking and
dependent on tobacco. If this is prescribed, offer it with behavioural
support. [2018]
1.12.4 Do not offer varenicline or bupropion to people under 18. [2013]
1.12.5 Offer behavioural support to people who smoke regardless of which
option they choose to help them stop smoking, unless they have chosen
the Allen Carr Easyway in-person group seminar. Explain how to access
this support. [2021, amended 2022]
1.12.6 Discuss with people which options to use to stop smoking, taking into
account:
? their preferences, health and social circumstances
? any medicines they are taking
? any contraindications and the potential for adverse effects
? their previous experience of stop-smoking aids.
Also see the advice in the recommendations on medicinally licensed products,
and the recommendations on nicotine-containing e-cigarettes. [2021]
1.12.7 Advise people (as appropriate for their age) that the following options,
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when combined with behavioural support, are more likely to result in
them successfully stopping smoking:
? varenicline (offered in line with NICE''s technology appraisal guidance on
varenicline for smoking cessation)
? a combination of short-acting and long-acting NRT
? nicotine-containing e-cigarettes.
In August 2022, varenicline was unavailable in the UK. See the MHRA alert on
varenicline. [2021]
1.12.8 Advise people (as appropriate for their age) that the options that are less
likely to result in them successfully stopping smoking, when combined
with behavioural support, are:
? bupropion
? short-acting NRT used without long-acting NRT
? long-acting NRT used without short-acting NRT. [2021]
1.12.9 For adults, prescribe or provide bupropion, varenicline or NRT before
they stop smoking:
? For bupropion agree a quit date set within the first 2 weeks of treatment,
reassess the person shortly before the prescription ends.
? For varenicline agree a quit date and start the treatment 1 to 2 weeks before
this date, reassess the person shortly before the prescription ends.
? For NRT agree a quit date and ensure the person has NRT ready to start the
day before the quit date.
In August 2022, varenicline was unavailable in the UK. See the MHRA alert on
varenicline. [2018]
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For a short explanation of why the committee made the 2021 and 2022
recommendations and how they might affect practice, see the rationale and impact
section on stop-smoking interventions.
Full details of the evidence and the committee''s discussion are in:
? evidence review L: barriers and facilitators to using e-cigarettes for cessation or
harm reduction
? evidence review M: long-term health effects of e-cigarettes
? evidence review K: cessation and harm-reduction treatments
? evidence review P: effectiveness and cost-effectiveness of Allen Carr''s Easyway.
Advice on medicinally licensed products
These recommendations are for people providing stop-smoking support or advice.
1.12.10 Emphasise that:
? most smoking-related health problems are caused by other components in
tobacco smoke, not by the nicotine
? any risks from using medicinally licensed nicotine-containing products or other
stop-smoking pharmacotherapies are much lower than those of smoking.
[2013, amended 2021]
1.12.11 Explain how to use medicinally licensed nicotine-containing products
correctly. This includes ensuring people know how to achieve a high
enough dose to:
? control cravings
? prevent compensatory smoking
? achieve their goals on stopping or reducing the amount they smoke. [2013]
1.12.12 Advise people using short-acting NRT to replace each cigarette with the
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product they are using, for example a lozenge or piece of gum. Ideally,
they should use this before the usual time they would have had the
cigarette, to allow for the slower nicotine release from these products.
[2013]
Advice on nicotine-containing e-cigarettes
These recommendations are for people providing stop-smoking support or advice to
adults.
1.12.13 Give clear, consistent and up-to-date information about nicotine-
containing e-cigarettes to adults who are interested in using them to
stop smoking (for example, see the NCSCT e-cigarette guide and Public
Health England''s information on e-cigarettes and vaping). [2021]
1.12.14 Advise adults how to use nicotine-containing e-cigarettes. This includes
explaining that:
? e-cigarettes are not licensed medicines but are regulated by the Tobacco and
Related Products Regulations (2016)
? there is not enough evidence to know whether there are long-term harms from
e-cigarette use
? use of e-cigarettes is likely to be substantially less harmful than smoking
? any smoking is harmful, so people using e-cigarettes should stop smoking
tobacco completely. [2021]
1.12.15 Discuss:
? how long the person intends to use nicotine-containing e-cigarettes for
? using them for long enough to prevent a return to smoking and
? how to stop using them when they are ready to do so. [2021]
1.12.16 Ask adults using nicotine-containing e-cigarettes about any side effects
or safety concerns that they may experience. Report these to the MHRA
Yellow Card scheme, and let people know they can report side effects
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directly. [2021]
1.12.17 Explain to adults who choose to use nicotine-containing e-cigarettes the
importance of getting enough nicotine to overcome withdrawal
symptoms, and explain how to get enough nicotine. [2021]
For a short explanation of why the committee made the 2021 recommendations and
how they might affect practice, see the rationale and impact section on advice on
nicotine-containing e-cigarettes.
Full details of the evidence and the committee''s discussion are in:
? evidence review L: barriers and facilitators to using e-cigarettes for cessation or
harm reduction
? evidence review M: long-term health effects of e-cigarettes
? evidence review K: cessation and harm-reduction treatments.
Telephone quitlines
1.12.18 Ensure publicly sponsored telephone stop-smoking quitlines offer a
rapid, positive and authoritative response. If possible, give callers whose
first language is not English access to information and support in their
chosen language. [2018]
1.12.19 Ensure all staff giving advice through stop-smoking quitlines receive
stop-smoking training (at least in brief interventions to help people stop
smoking). [2018]
1.12.20 Train staff who offer counselling through stop-smoking quitlines so that
they meet the NCSCT Training Standard (individual behavioural
counselling). Preferably, they should also have a relevant counselling
qualification. Training should comply with the NCSCT Training Standard
for training in smoking cessation treatments or its updates. [2008,
amended 2018]
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1.13 Support to stop smoking in primary care and
community settings
This recommendation is for health and social care professionals in primary care and
community settings. See recommendation 1.14.23 for advice on people''s use of prescribed
medicines that are affected by smoking (or stopping smoking).
Other recommendations to support pregnant women to stop smoking are in the section on
treating tobacco dependence in pregnant women.
1.13.1 For people who want to stop smoking:
? discuss with them how they can stop (NCSCT programmes explain how to do
this)
? provide stop-smoking interventions and advice; see the section on stop-
smoking interventions
? if you are unable to provide stop-smoking interventions, refer them to local
stop-smoking support, if available
? if they opt out of a referral to stop-smoking support, refer them to a
professional who can offer pharmacotherapy and very brief advice. [2018,
amended 2021]
1.14 Support to stop smoking in secondary care
services
These recommendations are for health and social care professionals in all acute, maternity
and mental health services (including both inpatient and community mental health
services, health visitors and midwives). Other recommendations to support pregnant
women to stop smoking are in the section on treating tobacco dependence in pregnant
women.
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Information on stopping smoking for those using acute,
maternity and mental health services
These recommendations are about information and support before any secondary care
admission.
1.14.1 Give people information about the smokefree policy before their
appointment, procedure or hospital stay. This should cover:
? the short- and long-term health benefits of stopping smoking at any time; for
example, stopping smoking at any time before surgery has no ill effects
(although people may experience short-term withdrawal symptoms such as
headaches or irritability from quitting), and people who stop in the 8 weeks
before surgery can benefit significantly
? the risks of secondhand smoke
? the fact that all buildings and grounds are smokefree so they must not smoke
while admitted to, using or visiting these services (see the section on policy)
? the types of support available to help them stop smoking completely or
temporarily before, during and after an admission or appointment (see the
sections on behavioural support in acute and mental health services and
supporting people who have to stop smoking temporarily)
? about the different pharmacotherapies that can help with stopping smoking
and temporary abstinence, where to obtain them (including from GPs) and how
to use them. [2013, amended 2021]
1.14.2 Before a planned or likely admission to an inpatient setting, work with the
person to include how they will manage their smoking on admission or
entry to the secondary care setting in their personal care plan. [2013]
1.14.3 Encourage people being referred for elective surgery to stop smoking
before their surgery. Refer them to local stop-smoking support. [2018]
1.14.4 Provide information and take the opportunity to provide advice to visitors
about the benefits of stopping smoking and how to contact local stop-
smoking support. [2013]
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Referring to behavioural support in acute, maternity and mental
health services
1.14.5 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. [2013]
1.14.6 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. [2013]
Behavioural support in acute and mental health services
These recommendations are for healthcare professionals, stop-smoking advisers and
others trained to provide behavioural support to stop smoking. For pregnant women, see
the section on providing support to stop smoking for pregnant women.
1.14.7 Discuss current and past smoking behaviour and develop a personal
stop-smoking plan as part of a review of the person''s health and
wellbeing. [2013]
1.14.8 Provide information about the different types of stop-smoking options
and how to use them. [2013, amended 2021]
1.14.9 Provide information about the types of behavioural support to stop
smoking available. [2013]
1.14.10 Offer and arrange or supply prescriptions of stop-smoking options (see
the sections on stop-smoking interventions and stop-smoking
pharmacotherapies in acute and mental health services). [2013,
amended 2021]
1.14.11 Offer to measure people''s exhaled carbon monoxide level during each
contact and use these measurements to motivate them to stop smoking
and provide feedback on their progress. [2013]
1.14.12 Alert the person''s other healthcare providers and prescribers to changes
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in smoking behaviour because dosages of other medicines may need
adjusting (see the section on drug dosages for people who have stopped
smoking). [2013]
1.14.13 For people who smoke who are admitted to secondary care, as well as
following the recommendations in this section:
? Provide immediate support if necessary, otherwise within 24 hours of
admission.
? Provide support (on site) as often and for as long as needed during admission.
? Offer weekly sessions, preferably face to face, for at least 4 weeks after
discharge. If it is not possible to provide this support after discharge, arrange a
referral to local stop-smoking support. [2013]
1.14.14 For people who smoke who are receiving secondary care services in the
community or at outpatient clinics (including preoperative assessments)
follow the recommendations in this section and:
? Provide immediate support at the outpatient site.
? Offer weekly sessions, preferably face to face, for at least 4 weeks after the
date they stopped smoking. Arrange a referral to local stop-smoking support if
the person prefers. [2013]
Stop-smoking pharmacotherapies in acute and mental health
services
For pregnant women, see recommendations on nicotine replacement therapy and other
pharmacological support in the pregnancy section.
Also see the recommendations on smoking in the physical health section of NICE''s
guideline on psychosis and schizophrenia in adults.
1.14.15 If stop-smoking pharmacotherapy is accepted, make sure it is provided
immediately. [2013]
1.14.16 Advise people to remove nicotine replacement therapy patches 24 hours
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before microvascular reconstructive surgery and surgery using
vasopressin injections. [2013]
1.14.17 When people are discharged from hospital, ensure they have enough
stop-smoking pharmacotherapy to last at least 1 week or until their next
contact with stop-smoking support. [2013]
1.14.18 Tell them about local policies on indoor and outdoor use of nicotine-
containing e-cigarettes. [2013, amended 2021]
See also the section on stop-smoking interventions.
Stop-smoking support in mental health services
1.14.19 For people with severe mental health conditions who may need
additional support to stop smoking, offer:
? delivery by a specialist adviser with mental health expertise
? support that is tailored in duration and intensity to the person''s needs. [2021]
See also the section on stop-smoking interventions.
For a short explanation of why the committee made the 2021 recommendation and
how it might affect practice, see the rationale and impact section on stop-smoking
support in mental health services.
Full details of the evidence and the committee''s discussion are in evidence review O:
tailored interventions for those with mental health conditions.
Supporting people who have to stop smoking temporarily
These recommendations are for health and social care professionals, stop-smoking
advisers and voluntary and community organisations.
1.14.20 For those who need to abstain temporarily to use acute and mental
health services:
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? tell them about the different types of medicinally licensed nicotine-containing
products and how to use them and
? encourage the use of medicinally licensed nicotine-containing products to help
them abstain and, if possible, prescribe them. [2013]
1.14.21 Provide behavioural support alongside medicinally licensed nicotine-
containing products to maintain abstinence from smoking while in
secondary care. [2013]
1.14.22 Offer behavioural support to people who want or need to abstain from
smoking temporarily in all settings, including closed institutions for
example. Support could include:
? one-to-one or group sessions by specialist services
? discussing why it is important to reduce the harm caused by smoking (to
others as well as themselves)
? encouraging people to consider other times or situations when they could stop.
[2013]
Medicine dosages for people who have stopped smoking
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).
1.14.23 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. [2013,
amended 2021]
1.14.24 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
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notice any side effects from changing the amount they smoke. [2013]
Making stop-smoking options available in hospital
These recommendations are for hospital pharmacists and managers.
1.14.25 Ensure hospital pharmacies stock the medicinally licensed products
recommended in the section on stop-smoking interventions for patients
and staff. [2013]
1.14.26 Ensure people using secondary care have access to stop-smoking
pharmacotherapies at all times. [2013]
See also recommendation 1.22.14.
Supporting staff in secondary care and closed institutions to stop
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.
1.14.27 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.
[2013]
1.14.28 Encourage staff to use stop-smoking support to stop or cut down the
amount they smoke. Provide contact details for community support if
preferred. [2013]
See also the section on stop-smoking interventions and the NCSCT''s service and delivery
guidance 2014.
Supporting staff in secondary care and closed institutions to
reduce their harm from smoking and comply with smokefree
policies
These recommendations are for providers of secondary care, and managers of closed
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institutions and other services where smoking is not permitted.
1.14.29 For staff in secondary care and closed institutions who do not want, or
are not ready, to stop smoking in one go:
? Ask them if they would like to think about reducing the harm from smoking (see
box 1).
? Advise them to use medicinally licensed nicotine-containing products to help
them not to smoke immediately before and during working hours. Advise them
where to get them. [2013]
1.14.30 Offer and provide behavioural support to help staff in secondary care
and closed institutions not to smoke during working hours. [2013]
1.15 Supporting people who do not want, or are not
ready, to stop smoking in one go to reduce their
harm from smoking
These recommendations are for providers of stop-smoking support and other specially
trained professionals.
Choosing a harm-reduction approach
1.15.1 Advise people that stopping smoking in one go is the best approach.
[2013]
1.15.2 If someone does not want, or is not ready, to stop smoking in one go, ask
if they would like to think about reducing the harm from smoking. If they
agree, help them to identify why they smoke, their smoking triggers and
their smoking behaviour. Use this information to work through the
approaches outlined in box 1. [2013]
1.15.3 Suggest which approaches to stopping smoking might be most suitable,
based on the person''s smoking behaviour, previous attempts to stop and
their health and social circumstances. Briefly discuss the merits of each
approach to help them choose. [2013]
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Box 1 Harm-reduction approaches
Cutting down before stopping smoking
? 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.
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.
[2013, amended 2021]
Medicinally licensed nicotine-containing products for harm
reduction
These recommendations are for health and social care professionals, stop-smoking
advisers and voluntary and community organisations.
1.15.4 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
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? 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. [2013]
1.15.5 Advise people that medicinally licensed nicotine-containing products can
be used for as long as they help stop them going back to previous levels
of smoking (see box 1). [2013, amended 2021]
1.15.6 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. [2013]
1.15.7 If more intensive support is needed, refer to stop-smoking support.
[2013]
Behavioural support for harm reduction
These recommendations are for stop-smoking advisers and those trained to provide
behavioural support to help people stop smoking, including telephone quitlines and
internet support sites.
1.15.8 Use the information gathered about smoking behaviour (see the section
on identifying and quantifying people''s smoking) to help people set goals
and discuss reduction strategies. This may include:
? increasing the time interval between cigarettes
? delaying the first cigarette of the day
? choosing periods during the day, or specific occasions, when they will not
smoke. [2013]
1.15.9 Help people who are cutting down before stopping smoking to set a
specific quit date. Normally this quit date should be within 6 weeks of
them starting behavioural support, although the sooner the better. Help
them to develop a schedule detailing how much they aim to cut down
(and when) in the lead up to that date. [2013]
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1.15.10 Help people who are aiming to reduce the amount they smoke (but not
intending to stop) to set a date when they will have achieved their goal.
Help them to develop a schedule for this or to identify specific periods of
time (or specific events) when they will not smoke. [2013]
1.15.11 Tell people who are not prepared to stop smoking that the health
benefits from reducing the amount they smoke are unclear. But advise
them that if they reduce their smoking now, they are more likely to stop
smoking in the future. Explain that this is particularly true if they use
medicinally licensed nicotine-containing products to help reduce the
amount they smoke. [2013]
1.15.12 If necessary, advise people how to use medicinally licensed nicotine-
containing products effectively. [2013]
Harm-reduction self-help materials
1.15.13 Provide self-help materials in a range of formats and languages, tailored
to meet the needs of groups in which smoking is widespread and many
people are dependent on tobacco, for example, those listed as being at
high risk of harm in the section on commissioning and designing
services. [2013, amended 2021]
1.15.14 Self-help materials for people who smoke should include advice about
the areas covered in the section on choosing a harm-reduction approach,
as well as details of where to find more help and support. Use social
media websites to publicise self-help materials. [2013]
Manufacturer information supplied with medicinally licensed
nicotine-containing products
1.15.15 Provide consumers with clear, accurate information on the health risks of
any medicinally licensed nicotine-containing product, compared with
continuing to smoke and not smoking. Include details on long-term use.
[2013]
1.15.16 Provide simple, clear instructions on how to use medicinally licensed
nicotine-containing products to support the harm-reduction approaches
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outlined in box 1. [2013]
1.15.17 Think about providing information on the outer packaging as well as in
the enclosed leaflet for medicinally licensed nicotine-containing
products. [2013]
1.15.18 Package medicinally licensed nicotine-containing products in a way that
makes it as easy as possible for people to take the recommended dose
for the right amount of time. [2013]
1.16 Stopping use of smokeless tobacco
Identifying people who use smokeless tobacco and offering
referral
These recommendations are for GPs, dentists, pharmacists and other healthcare
professionals, particularly those providing services for South Asian communities.
1.16.1 Ask people if they use smokeless tobacco, using the names that the
various products are known by locally. If necessary, use visual aids to
show them what the products look like. (This may be necessary if the
person does not speak English well or does not understand the terms
being used.) Record the outcome in the person''s notes. [2012]
1.16.2 If someone uses smokeless tobacco, ensure they are aware of the health
risks (for example, the risk of cardiovascular disease, oropharyngeal
cancers and periodontal disease). Use a brief intervention to advise them
to stop. [2012]
1.16.3 Refer people who use smokeless tobacco who want to quit to local
specialist tobacco cessation services (see the section on stop-smoking
interventions). This includes services specifically for South Asian groups,
where they are available. [2012]
1.16.4 Record the person''s response to any attempts to encourage or help them
to stop using smokeless tobacco in their notes (as well as recording
whether they smoke). [2012]
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Providing support to stop using smokeless tobacco
These recommendations are for people providing support or advice as part of a
comprehensive specialist tobacco cessation service.
1.16.5 Use the local names when referring to smokeless tobacco products.
[2012, amended 2021]
1.16.6 Provide advice on how to quit to people who use smokeless tobacco (or
recommend that they get advice to help them quit). [2012, amended
2021]
1.16.7 Offer people who use smokeless tobacco help to prevent a relapse after
an attempt to stop. If possible, check the success of the attempt by
using a cotinine test (saliva examination). Monitor for any possible
increase in tobacco smoking or use of areca nut. [2012, amended 2021]
1.16.8 Advise people on how to cope with the potential adverse effects of
quitting smokeless tobacco. This may include, for example, referring
people for help to cope with oral pain, as well as providing general
support to cope with withdrawal symptoms. [2012, amended 2021]
1.16.9 Check whether smokeless tobacco users also smoke tobacco and, if that
is the case, provide help to quit them both. [2012, amended 2021]
Developing services for people using smokeless tobacco
Assessing local need for smokeless tobacco services for South Asian
communities
These recommendations are for people who commission, plan and run services to help
people stop using tobacco.
1.16.10 As part of the local joint strategic needs assessment, gather information
on where, when and how often smokeless tobacco cessation services
are promoted and provided to local South Asian communities – and by
whom. Aim to get an overview of the services on offer. [2012]
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1.16.11 Consult with local voluntary and community organisations that work with,
or alongside, South Asian communities to understand their specific
issues and needs in relation to smokeless tobacco (see the section on
working with local South Asian communities). [2012]
1.16.12 Collect and analyse data on the use of smokeless tobacco among local
South Asian communities. For example, collect data from local South
Asian voluntary and community organisations, dental health
professionals and primary and secondary care services. This data should
provide information on:
? prevalence and incidence of smokeless tobacco use and detail on the people
who use it (for example, their age, family origin, gender, language, religion,
disability status and socioeconomic status)
? people who use smokeless tobacco and do not use cessation services
? types of smokeless tobacco used
? perceived level of health risk associated with these products
? circumstances in which these products are used locally
? proportion and demographics of people who both smoke and use smokeless
tobacco products. [2012]
1.16.13 When collecting and analysing information on smokeless tobacco, use
consistent terminology to describe the products. Note any local variation
in the terminology used by retailers and consumers. [2012]
1.16.14 Think about working with neighbouring local authorities to analyse
routinely collected data from a wider geographical area on the health
problems associated with smokeless tobacco among local South Asian
communities. In particular, collect and analyse data on the rate of
oropharyngeal cancers. Note any demographic patterns. Data could be
gathered from local cancer registers, Hospital Episode Statistics, joint
strategic needs assessments and local cancer networks. [2012]
1.16.15 Collect information from tobacco cessation services on the number of
South Asian people who have recently sought help to give up smoking or
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smokeless tobacco. Depending on the level of detail available, data
should be broken down demographically (for example, by age, family
origin, gender, religion and socioeconomic status). [2012]
Working with local South Asian communities
These recommendations are for public sector, voluntary and community organisations,
health and social care professionals and faith groups.
1.16.16 Work with local South Asian communities to plan, design, coordinate,
implement and publicise activities to help them stop using smokeless
tobacco:
? Develop relationships and build trust between relevant organisations,
communities and people by involving them in all aspects of planning.
? Take account of existing and past activities to address smokeless tobacco use
and other health issues among these communities.
? Also see NICE''s guideline on community engagement: improving health and
wellbeing and reducing health inequalities. [2012]
1.16.17 Work with local South Asian communities to understand how to make
smokeless tobacco cessation services more accessible. For example, if
smokeless tobacco cessation services are provided within existing
mainstream stop-smoking support, find out what would make it easier for
South Asian people to use the service. [2012]
Commissioning and providing smokeless tobacco services
These recommendations are for directors of public health and those responsible for
commissioning and managing tobacco cessation services.
1.16.18 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. [2012]
1.16.19 Provide services for South Asian users of smokeless tobacco either
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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.) [2012]
1.16.20 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). [2012]
1.16.21 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. [2012]
1.16.22 Ensure smokeless tobacco cessation services take into account the fact
that some people who use smokeless tobacco products also smoke.
[2012]
1.16.23 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
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? 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. [2012]
Monitoring smokeless tobacco cessation services
1.16.24 Regularly monitor and evaluate all local smokeless tobacco cessation
services (and activities to promote them). Ensure they are effective and
acceptable to service users. If necessary, adjust services to meet local
need more effectively. The following outcomes should be reported:
? number of quit attempts
? percentage of successful quit attempts at 4 weeks
? percentage of quit attempts leading to an adverse or unintended consequence
(such as someone switching to, or increasing, their use of smoked tobacco or
areca nut-only products). [2012]
1.17 Adherence and relapse prevention
These recommendations are for people providing stop-smoking support or advice.
Supporting people trying to stop smoking
1.17.1 Discuss ways of preventing a relapse to smoking. This could include
talking about coping strategies and practical ways of making it easier to
prevent a relapse to smoking. Do this at an early stage and at each
contact. [2021]
1.17.2 Offer the opportunity for a further course of varenicline, NRT or
bupropion to prevent a relapse to smoking.
In November 2021, this was an off-label use of bupropion. See NICE''s
information on prescribing medicines.
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In August 2022, varenicline was unavailable in the UK. See the MHRA
alert on varenicline. [2021]
For a short explanation of why the committee made the 2021 recommendations and
how they might affect practice, see the rationale and impact section on supporting
people trying to stop smoking.
Full details of the evidence and the committee''s discussion are in evidence review N:
smoking relapse prevention.
Supporting people cutting down or stopping temporarily
1.17.3 If people who set out to reduce the amount they smoke or to stop
temporarily have been successful, assess how motivated they are to:
? maintain that level
? reduce the amount they smoke even more
? stop completely. [2013]
1.17.4 At appropriate intervals, measure people''s exhaled breath for carbon
monoxide to gauge their progress and help motivate them to stop
smoking. Ask them whether daily activities, for example climbing the
stairs or walking uphill, have become easier. Use this feedback to prompt
discussion about the benefits of cutting down and, if appropriate, to
encourage them to cut down even more or stop completely. [2013]
1.17.5 Offer medicinally licensed nicotine-containing products, as needed, to
help prevent a relapse among people who have reduced the amount they
smoke. [2013, amended 2021]
Reviewing the approach for people trying to stop smoking,
cutting down or stopping temporarily
1.17.6 For people attempting to stop smoking and those reducing their harm,
offer follow-up appointments and review the approach taken at each
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contact. [2021]
1.17.7 Encourage people who have not achieved their quitting or harm-
reduction goals to try again. Remind them that various interventions are
available to help them and discuss which option to use next. See the
sections on stop-smoking interventions and on supporting people who
do not want, or are not ready, to stop smoking in one go to reduce their
harm from smoking. [2021]
For a short explanation of why the committee made the 2021 recommendations and
how they might affect practice, see the rationale and impact section on reviewing the
approach.
Full details of the evidence and the committee''s discussion are in evidence review N:
smoking relapse prevention.
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Recommendations on treating tobacco
dependence in pregnant women
People have the right to be involved in discussions and make informed decisions
about their care, as described in NICE''s information on making decisions about 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.
This guideline should be read alongside NICE''s guidelines on patient experience in
adult NHS services and babies, children and young people''s experience of
healthcare, which have guidance on giving information to people and discussing their
views and preferences.
At the time of publication (November 2021), no nicotine-containing e-cigarettes were
licensed as a medicine for stopping smoking by the Medicines and Healthcare
products Regulatory Agency (MHRA) and commercially available in 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.
These recommendations aim to help women stop smoking during pregnancy and in the
first year after childbirth.
Other recommendations relevant to pregnant women are in the section on support to stop
smoking in secondary care services.
1.18 Identifying pregnant women who smoke and
referring them for stop-smoking support
These recommendations are for healthcare professionals providing maternity care.
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1.18.1 Provide routine carbon monoxide testing at the first antenatal
appointment and at the 36-week appointment to assess every pregnant
woman''s exposure to tobacco smoke. Provide carbon monoxide testing
at all other antenatal appointments if the pregnant woman:
? smokes or
? is quitting or
? used to smoke or
? tested with 4 parts per million (ppm) or above at the first antenatal
appointment. [2023]
1.18.2 Provide an opt-out referral to receive stop-smoking support for all
pregnant women who:
? say they smoke or have stopped smoking in the past 2 weeks or
? have a carbon monoxide reading of 4 ppm or above or
? have previously been provided with an opt-out referral but have not yet
engaged with stop-smoking support.
See also the section on identifying smoking among carers, family and other
household members. [2021]
1.18.3 Explain to the woman:
? that it is normal practice to refer all pregnant women who smoke or have
recently quit
? that the carbon monoxide test will allow her to see a physical measure of her
smoking and exposure to other people''s smoking
? what her carbon monoxide reading means, taking into consideration the time
since she last smoked and the number of cigarettes smoked (and when) on the
day of the test. [2021]
1.18.4 If the pregnant woman does not smoke but has a carbon monoxide level
of 3 ppm or more, help her to identify the source of carbon monoxide
and reduce it. (Other sources include household or other secondhand
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smoke, heating appliances or traffic emissions.) [2013]
1.18.5 If the pregnant woman has a high carbon monoxide reading (more than
10 ppm) but says she does not smoke:
? advise her about possible carbon monoxide poisoning
? ask her to contact the Gas Emergency Line (0800 111 999) for gas safety
advice
? phrase any further questions about smoking sensitively to encourage a frank
discussion. [2010]
1.18.6 Record carbon monoxide level and any feedback given in the pregnant
woman''s antenatal records. If her antenatal records are not available
locally, use local protocols to record this information. [2010]
For a short explanation of why the committee made the 2021 recommendations and
how they might affect practice, see the rationale and impact section on identifying
pregnant women who smoke and referring them for stop-smoking support.
Full details of the evidence and the committee''s discussion are in evidence review H:
opt-out stop-smoking support.
1.19 Following up women who have been referred
for stop smoking support
These recommendations are for people providing stop-smoking support or advice.
1.19.1 Contact all pregnant women who have been referred for help. Discuss
smoking and pregnancy and the issues they face, using an impartial,
person-centred approach. Invite them to use the service. If necessary
(and resources permit), make at least 3 contacts using different
methods. Advise the maternity booking midwife of the outcome. [2010]
1.19.2 Try to see pregnant women who cannot be contacted by other methods.
This could happen during a routine antenatal care visit (for example,
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when they attend for a scan). [2010]
1.19.3 Provide information about the risks of smoking to an unborn child and the
benefits of stopping for both mother and baby. [2010]
1.19.4 Address any factors that prevent pregnant women from using stop-
smoking support. This could include:
? a lack of confidence in their ability to quit
? lack of knowledge about the services on offer
? difficulty accessing them
? lack of suitable childcare
? fear of failure and concerns about being stigmatised. [2010]
1.19.5 If pregnant women are reluctant to attend the stop-smoking service,
think about providing structured self-help materials or giving details of
telephone quitlines or NHS online stop-smoking support. Also think
about offering to visit them at home, or at another venue, if it is difficult
for them to attend specialist services. [2010]
1.19.6 Address any concerns pregnant women and their partners or family may
have about stopping smoking and offer personalised information, advice
and support on how to stop. [2010]
1.19.7 Send information on smoking and pregnancy to women who opt out
during the initial telephone call. This should include details on how to get
help to quit at a later date. [2010]
1.20 Providing support to stop smoking
These recommendations are for people providing stop-smoking support or advice.
1.20.1 Provide the pregnant woman with intensive and ongoing support (brief
interventions alone are unlikely to be sufficient) throughout pregnancy
and beyond. This includes regularly monitoring her smoking status using
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carbon monoxide tests. Use carbon monoxide measurements to
encourage her to quit and as a way to provide positive feedback once a
quit attempt has been made. [2010]
1.20.2 Biochemically validate that the pregnant woman has quit on the date she
set and 4 weeks after. If possible, use urine or saliva cotinine tests, as
these are more accurate than carbon monoxide tests. (They can detect
exposure over the past few days rather than hours.) [2010]
1.20.3 When carrying out tests, check whether the pregnant woman is using
nicotine replacement therapy (NRT) as this may raise her cotinine levels.
Take into account that no measure can be 100% accurate. Some people
may smoke so infrequently – or inhale so little – that their intake cannot
reliably be distinguished from that from passive smoking. [2010]
1.20.4 If the pregnant woman stopped smoking in the 2 weeks before her
maternity booking appointment, continue to provide support in line with
the recommendations above and stop-smoking support practice
protocols. [2010]
1.20.5 Establish links with contraceptive services, fertility clinics and antenatal
and postnatal services so that everyone working in those organisations
knows about local stop-smoking support. Ensure they understand what
these services offer and how to refer people to them. [2010]
For pregnant women taking prescribed medicines, also see the section on medicine
dosages for people who have stopped smoking.
Nicotine replacement therapy and other pharmacological support
1.20.6 Consider NRT alongside behavioural support to help women stop
smoking in pregnancy (see BNF information on NRT). [2021]
1.20.7 Consider NRT at the earliest opportunity in pregnancy and continue to
provide it after pregnancy if the woman needs it to prevent a relapse to
smoking, including if the pregnancy does not continue (see BNF
information on NRT). [2021]
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1.20.8 Give pregnant women clear and consistent information about NRT.
Explain:
? that it may help them stop smoking and reduce their cravings
? how to use NRT correctly, including how to get a high enough dose of nicotine
to control cravings, prevent compensatory smoking and stop successfully.
[2021]
1.20.9 Advise pregnant women who are using nicotine patches to remove them
before going to bed. [2010]
1.20.10 Emphasise to pregnant women that:
? most smoking-related health problems are caused by other components in
tobacco smoke, not by the nicotine
? any risks from using NRT are much lower than those of smoking
? nicotine levels in NRT are much lower than in tobacco, and the way these
products deliver nicotine makes them considerably less addictive than
smoking. [2021]
1.20.11 Do not offer varenicline or bupropion to pregnant or breastfeeding
women. [2010]
For a short explanation of why the committee made the 2021 recommendations and
how they might affect practice, see the rationale and impact section on nicotine
replacement therapy and other pharmacological support.
Full details of the evidence and the committee''s discussion are in evidence review J:
nicotine replacement therapy and e-cigarettes in pregnancy: update.
Incentives to stop smoking
These recommendations are for providers of stop-smoking support.
1.20.12 In addition to NRT and behavioural support, offer voucher incentives to
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support women to stop smoking during pregnancy, as follows:
? refer women to an incentive scheme at the first maternity booking appointment
or at the next available opportunity
? provide vouchers only for abstinence validated using a biochemical method,
such as a carbon monoxide test with a reading of less than 4 ppm
? stagger incentives until at least the end of pregnancy (incentives totalling
around ￡400 have been shown to be effective)
? do not exclude women who have relapsed or those whose pregnancy does not
continue from continuing to take part in the scheme and try again
? ensure vouchers cannot be used to buy products that could be harmful during
pregnancy (for example, alcohol and cigarettes). [2021]
1.20.13 Consider providing voucher incentives jointly to the pregnant woman and
to a friend or family member that she has chosen to support her during
her quit attempt. [2021]
1.20.14 Ensure staff are trained to promote and deliver incentive schemes to
pregnant women to stop smoking. [2021]
For a short explanation of why the committee made the 2021 recommendations and
how they might affect practice, see the rationale and impact section on incentives to
stop smoking.
Full details of the evidence and the committee''s discussion are in evidence review I:
incentives during pregnancy.
Enabling all pregnant women to access stop-smoking support
These recommendations are to help providers of stop-smoking support reach all pregnant
women, including those whose circumstances may make it more difficult to use services
(for example, because of cultural or sociodemographic factors, age or language).
1.20.15 Involve pregnant women who find it difficult to use or access existing
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stop-smoking support in the planning and development of services.
[2010]
1.20.16 Collaborate with the family nurse partnership and other outreach
schemes to identify additional opportunities for providing intensive and
ongoing support to pregnant women to stop smoking. (Note: family
nurses make frequent home visits.) [2010]
1.20.17 Work in partnership with agencies that support pregnant women who
have complex social and emotional needs. This includes substance
misuse services, youth and teenage pregnancy support and mental
health services. [2010]
Helping partners and others in the household who smoke
These recommendations are for providers of stop-smoking support. See also the section
on identifying smoking among carers, family and other household members.
1.20.18 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. [2010]
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Recommendations on policy,
commissioning and training
People have the right to be involved in discussions and make informed decisions
about their care, as described in NICE''s information on making decisions about 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.
This guideline should be read alongside NICE''s guidelines on patient experience in
adult NHS services and babies, children and young people''s experience of
healthcare, which have guidance on giving information to people and discussing their
views and preferences.
In this guideline, we use the following terms for age groups:
? children: aged 5 to 11
? young people: aged 12 to 17
? young adults: aged 18 to 24
? adults: aged 18 and over.
At the time of publication (November 2021), no nicotine-containing e-cigarettes were
licensed as a medicine for stopping smoking by the Medicines and Healthcare
products Regulatory Agency (MHRA) and commercially available in 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.
These recommendations are for people with responsibility for developing smokefree
policy, and for commissioning and training services.
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1.21 Policy
1.21.1 Develop a policy for smokefree grounds in collaboration with secondary
care staff and people who use secondary care services, including
services in the community, or their representatives. The policy should:
? set out a clear timeframe to establish or reinstate smokefree grounds
? identify the roles and responsibilities of staff
? ban staff from supervising or helping people to take smoking breaks
? identify the resources needed to support the policy
? ban the sale of tobacco products
? be periodically reviewed and updated, in line with all other organisational
policies. [2013]
1.21.2 Ensure smokefree implementation plans include:
? support for staff and people who use secondary care services to stop smoking
completely or temporarily
? training for staff (see the section on training for healthcare staff)
? removing shelters or other designated outdoor smoking areas
? staff, contractor and volunteer contracts that do not allow smoking during work
hours or when recognisable as an employee (for example, when in uniform,
wearing identification, or handling hospital business)
? how secondary care staff can work with people who use services and carers to
protect themselves from tobacco smoke when they visit people''s homes. (In
accordance with smokefree legislation, employers must take action to reduce
the risk to the health and safety of their employees from secondhand smoke to
as low a level as is reasonably practicable.) [2013]
1.21.3 Ensure policies, procedures and resources are in place to:
? help comply with, and resolve immediately, any breaches of smokefree policies,
including a process for staff to report incidents
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? support staff to encourage others to comply with the smokefree policy
? work with people who use services, carers, visitors and staff to overcome any
problems that may result from smoking restrictions (supported by ''personal
care plans'' as covered in the section on information on stopping smoking for
those using acute, maternity and mental health services). [2013]
1.21.4 Ensure all staff are aware of the smokefree policy and comply with it.
[2013]
Communicating the smokefree policy
1.21.5 Develop, deliver and maintain a communications strategy on local
smokefree policy requirements. This could include newsletters,
pamphlets, posters and signage (smokefree signs for vehicles or areas
that are enclosed or substantially enclosed must comply with regulations
under the Health and Safety at Work etc Act 1974). Include information
for people who use secondary care services, their parents or carers, staff
and visitors, and the wider local population. Also include:
? clear, consistent messages about the need to keep buildings and grounds
smokefree
? positive messages about the health benefits of a smokefree environment
? the fact that health and social care professionals have a duty to provide a safe,
healthy environment for staff and people who use or visit secondary care
services
? information about stop-smoking support and how to access services, including
support to temporarily stop, for staff and people who use secondary care
services
? the fact that staff are not allowed to smoke at any time during working hours or
when recognisable as an employee, contractor or volunteer (for example, when
in uniform, wearing identification, or handling hospital business). [2013]
Closed institutions
1.21.6 Include management of smoking in the care plan of people in closed
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institutions who smoke. [2013]
1.21.7 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. [2018]
See also the sections on employers, support to stop smoking in secondary care services
and supporting people who do not want, or are not ready, to stop smoking in one go to
reduce their harm from smoking.
Ensuring local tobacco control strategies include secondary care
These recommendations are for people with responsibility for planning, commissioning and
running tobacco control strategies.
1.21.8 Ensure the joint strategic needs assessment:
? takes into account the impact of smoking on local communities
? identifies expected numbers of particular groups of people who are at very
high risk of tobacco-related harm (for example, those listed as being at high
risk of harm in the section on commissioning and designing services)
? identifies the proportion of people at very high risk reached by services and
the numbers who successfully stop smoking. [2013]
1.21.9 Make it clear in the local tobacco control strategy that people working in
secondary care should:
? communicate key messages about tobacco-related harm to everyone who
uses services
? develop policies and support to help people stop smoking
? identify people who want to stop smoking and, if appropriate, refer them to a
stop-smoking adviser
? implement a comprehensive smokefree policy that includes the grounds of the
establishment. [2013]
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1.21.10 Develop a local stop-smoking care pathway and referral procedure to
ensure there is continuity of care between primary, community and
secondary care. [2013]
1.22 Commissioning and designing services
These recommendations are for directors and senior managers in settings where stop-
smoking support is needed, and commissioners, providers and managers of stop-smoking
support.
1.22.1 Use integrated care systems plans, health and wellbeing strategies, and
other relevant local strategies and plans to make the range of
interventions in the section on stop-smoking interventions accessible to
adults who smoke. [2021]
1.22.2 Ensure service specifications require providers of stop-smoking support
to offer nicotine replacement therapy (NRT) for as long as needed to help
prevent a relapse to smoking. [2021]
1.22.3 Use the government''s local tobacco control profiles to estimate smoking
prevalence among the local population. [2018]
1.22.4 Prioritise groups at high risk of tobacco-related harm. These may include:
? people with mental health conditions (for example, see NICE''s guideline on
depression in adults)
? people who misuse substances (for example, see NICE''s guideline on
coexisting severe mental illness and substance misuse: community health and
social care services)
? people with health conditions caused or made worse by smoking (for example,
see NICE''s guidelines on cardiovascular disease: identifying and supporting
people most at risk of dying early, type 1 diabetes in adults, asthma and
chronic obstructive pulmonary disease)
? people with a smoking-related illness (see NICE''s guideline on lung cancer)
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? populations with a high prevalence of smoking-related morbidity or a
particularly high susceptibility to harm
? communities or groups with particularly high smoking prevalence (such as
manual workers, travellers and LGBT+ people)
? people with a low socioeconomic status
? pregnant women who smoke. [2018]
For a short explanation of why the committee made the 2021 recommendations and
how they might affect practice, see the rationale and impact section on
commissioning and designing services.
Full details of the evidence and the committee''s discussion are in:
? evidence review N: smoking relapse prevention
? evidence review K: cessation and harm-reduction treatments.
Providing stop-smoking support to employers
1.22.5 Offer support to employers who want to help their employees to stop
smoking. If appropriate and feasible, provide support on the employer''s
premises. [2007]
1.22.6 If initial demand exceeds the resources available, focus on the following:
? small and medium-sized enterprises
? enterprises with a high proportion of employees on low pay
? enterprises with a high proportion of employees at high risk of tobacco-related
harm. [2007]
Harm reduction within stop-smoking support
1.22.7 Ensure investment in harm-reduction approaches does not detract from,
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but supports and extends the reach and impact of, existing stop-smoking
support. [2013]
1.22.8 Develop stop-smoking referral and treatment pathways to ensure a
range of approaches and interventions is available to support people
who opt for a harm-reduction approach (see box 1). [2013]
1.22.9 Ensure service specifications require providers of stop-smoking support
to offer medicinally licensed nicotine-containing products on a long-term
basis to help people maintain a lower level of smoking. [2013, amended
2021]
Stop-smoking support in secondary care
1.22.10 Ensure all secondary care buildings and grounds are smokefree. [2013]
1.22.11 Ensure the NHS standard contract and local authority contract includes
smokefree strategies. [2013]
1.22.12 Ensure all hospitals have on-site stop-smoking support. [2013]
1.22.13 Ensure stop-smoking medicinally licensed products are included in
secondary care formularies. [2013]
1.22.14 Include NICE-recommended nicotine-containing products as options for
sale in secondary care settings (for example, in hospital shops). [2021]
1.22.15 Ensure secondary care service specifications and service-level
agreements require:
? all staff to be trained to give advice on stopping smoking and to make a referral
to behavioural support
? relevant staff to undertake regular continuing professional development in how
to provide behavioural support to stop smoking. [2013]
1.22.16 Monitor and audit the implementation and impact of recommendations
for secondary care services. This may include recording:
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? individual smoking status (including for pregnant women at the time of giving
birth)
? number of referrals
? uptake of interventions
? prescribing of stop-smoking pharmacotherapies
? 4-week quit rates
? staff training.
Ensure the needs of higher-risk groups identified in the joint strategic needs
assessment are being met (see the section on ensuring local tobacco control
strategies include secondary care). [2013]
1.22.17 Ensure secondary care providers have enough resources to maintain a
smokefree policy. [2013]
1.22.18 Ensure secondary care pathways cover the following actions:
? identifying people who smoke
? providing advice on likely smoking-related complications
? providing advice on how to stop smoking
? proactively referring people to stop-smoking support. [2013]
1.22.19 Secondary care directors and managers leading on stop-smoking
support should assign a clinical or medical director to lead on stop-
smoking support for people who use, or work in, secondary care
services. As well as implementing the recommendations in this guideline
on providing and commissioning stop-smoking support in secondary
care, the designated lead should ensure:
? the organisation has an annual improvement programme for stop-smoking
support given to people who use, or work in, secondary care services
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? stop-smoking support (for patients and staff) is promoted and communicated
effectively (see the section on communicating the smokefree policy) to start a
cultural change within the organisation
? the quality of stop-smoking support continues to improve
? performance monitoring and feedback on outcomes is provided to all staff.
[2013]
For a short explanation of why the committee made the 2021 recommendation and
how it might affect practice, see the rationale and impact section on stop-smoking
support in secondary care.
Full details of the evidence and the committee''s discussion are in evidence review K:
cessation and harm-reduction treatments.
Referral systems for people who smoke
1.22.20 Ensure there are systems for consistently recording and maintaining
records of smoking status. All patient records should:
? provide a prompt for action (including referral to stop-smoking support)
? be stored for easy access and audit. [2013]
1.22.21 Make sure there is a robust system (preferably electronic) to support
continuity of care between secondary care and local stop-smoking
support for people moving in and out of secondary care. [2013]
Monitoring stop-smoking services by commissioners and
managers
1.22.22 Set targets for stop-smoking services, including the number of people
using the service and the proportion who successfully stop smoking.
Performance targets should include:
? treating at least 5% of the estimated local population who smoke each year
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? achieving a stop-smoking rate of at least 35% at 4 weeks, based on everyone
who starts treatment and defining success as not having smoked (confirmed
by carbon monoxide monitoring of exhaled breath) in the fourth week after the
quit date. [2018]
1.22.23 Check self-reported smoking abstinence using a carbon monoxide test.
Define success 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. [2018]
1.22.24 Monitor performance data for stop-smoking services routinely and
independently. Make the results publicly available. [2018]
1.22.25 Audit exceptional results (for example, 4-week smoking quit rates lower
than 35% or above 70%). Use the audit to determine the reasons for
unusual performance as well as to identify good practice and ensure it is
being followed. [2018]
1.22.26 Assess the performance of providers that support people who want to
reduce the harm from smoking. Additional measures could include:
? numbers attending the services (for comparison with the numbers attending
before harm-reduction options were offered)
? classifying the harm-reduction approaches used (see box 1)
? characteristics of people using the service (such as demographic data,
cigarette usage, level of dependency and previous attempts to stop)
? type and amount of medicinally licensed nicotine-containing products supplied
or prescribed, and over-the-counter sales of these products
? number of people setting a quit date. [2013]
1.23 Training
Training to prevent uptake of smoking
This recommendation is for those with responsibility for improving the health and
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wellbeing of children, young people and young adults who attend school.
1.23.1 Work in partnership with those involved in smoking prevention and stop-
smoking activities to design, deliver, monitor and evaluate smoking
prevention training and interventions. Partners could include:
? national and local education agencies
? training agencies
? local authorities
? tobacco control alliances
? school nursing service
? voluntary sector organisations
? local health improvement services
? providers of stop-smoking support
? universities. [2010]
See also NICE''s guidelines on behaviour change: general approaches and alcohol
interventions in secondary and further education.
Training on stopping smoking
Healthcare staff
1.23.2 Train all frontline healthcare staff to offer very brief advice on how to
stop smoking in accordance with the section on support to stop smoking
in primary care and community settings. Also train them to make
referrals, if necessary and possible, to local stop-smoking support.
Frontline secondary care staff should also be trained to refer people for
behavioural support. [2013, amended 2018]
1.23.3 Provide additional, specialised training on providing stop-smoking
support for those working with specific groups, for example people with
mental health conditions and pregnant women who smoke. [2008,
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amended 2018]
1.23.4 Encourage and train healthcare professionals to ask people about
smoking and to advise them of the dangers of exposure to secondhand
smoke. [2008, amended 2018]
People working in closed institutions
1.23.5 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. [2013]
1.23.6 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. [2013]
1.23.7 Ensure staff understand that if someone reduces the amount they
smoke, or stops completely, this can affect psychotropic and some other
medications (see the summaries of product characteristics for individual
drugs in the electronic medicines compendium for further details).
Ensure arrangements are in place to adjust their medication accordingly.
See the section on medicine dosages for people who have stopped
smoking. [2013]
1.23.8 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. [2013]
Midwives and others working with pregnant women
1.23.9 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
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? know about the treatments that can help people to quit, including nicotine
replacement therapy
? know how to refer people who smoke to local services for treatment.
See the National Centre for Smoking Cessation and Training''s (NCSCT) module
on very brief advice on smoking for pregnant women. [2010, amended 2021]
1.23.10 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. [2010]
1.23.11 Ensure that all healthcare and other professionals who work with
pregnant women (see recommendation 1.23.10):
? 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. [2010]
1.23.12 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
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NCSCT. Also provide additional, specialised training and offer them
ongoing support and training updates.
See the NCSCT''s specialty module on pregnancy and the postpartum
period. [2010]
1.23.13 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.
[2010]
Healthcare staff and others who advise people how to stop using smokeless
tobacco
1.23.14 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. [2012]
1.23.15 Ensure training helps professionals to:
? recognise the signs of smokeless tobacco use
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? 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. [2012]
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Terms used in this guideline
This section defines terms that have been used in a particular way for this guideline. For
other definitions, see the NICE glossary or, for public health and social care terms, the
Think Local Act Personal Care and Support Jargon Buster.
Allen Carr''s in-person group seminar
A session lasting between 4.5 and 6 hours with elements of cognitive behavioural therapy
and a brief relaxation exercise. Participants are encouraged to carry on smoking as normal
until they attend the session and to smoke as normal during scheduled smoking breaks
(around every 45 to 60 minutes) until a final ritual cigarette at the end. After the session,
regular texts remind participants that they can contact the provider if they have further
questions. The price includes up to 2 shorter (around 3.5 hours) follow-up sessions if
wanted.
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 NICE''s guideline on behaviour change: general approaches
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. Behavioural support does not include Allen Carr''s Easyway in-person
group seminar.
Cessation
Stopping the use of tobacco, smoked or smokeless. This includes stopping use of tobacco
and moving on to pharmacotherapies (including nicotine replacement therapy) or nicotine-
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containing e-cigarettes.
Closed institutions
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 places like long-stay mental health units and military
establishments.
Compensatory smoking
Inhaling more deeply or smoking more of each cigarette to compensate for smoking fewer
cigarettes.
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
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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 MHRA.
At the time of publication (November 2021), nicotine replacement therapy 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 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 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-containing e-cigarettes
Nicotine-containing e-cigarettes are vaping devices filled with nicotine-containing e-liquid.
These devices must be notified to the 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).
Nicotine replacement therapy
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.
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Pharmacotherapies
This covers medication licensed for smoking cessation such as varenicline or bupropion,
as well as nicotine replacement therapy. In August 2022, varenicline was unavailable in the
UK. See the MHRA alert on varenicline.
Safety
This refers to the incidence of minor and major side effects associated with nicotine-
containing products.
Schools
''Schools'' 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
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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.
Smokefree
Air that is free of tobacco smoke. E-cigarettes are not covered by smokefree legislation.
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 Products 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).
South Asian family origin
People with ancestral links to countries in southern Asia, including Bangladesh, India,
Nepal, Pakistan or Sri Lanka.
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
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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.
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 some time afterwards, depending on the person''s needs.
Stop-smoking support
Interventions and support to stop smoking, regardless of how services are commissioned
or set up.
Telephone quitlines
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.
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.)
Under-served groups
Groups who may be less likely to benefit from an intervention because they have specific
needs that the intervention does not address, or because they may face additional
challenges in engaging with the intervention.
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Recommendations for research
The guideline committee has made the following recommendations for research.
Key recommendations for research
1 Health effects of e-cigarettes
What are the short- and long-term health effects of e-cigarette use? Are there any specific
health effects relating to use in pregnancy, or use by children and young people? [2021]
For a short explanation of why the committee made the recommendation for research,
see the rationale section on advice on nicotine-containing e-cigarettes.
Full details of the evidence and the committee''s discussion are in:
? evidence review K: cessation and harm-reduction treatments
? evidence review M: long-term health effects of e-cigarettes.
2 Nicotine replacement therapy and e-cigarettes and pregnancy
Are nicotine replacement therapy or nicotine-containing e-cigarettes effective to help
women stop smoking in pregnancy (and at what dose)? [2021]
For a short explanation of why the committee made the recommendation for research,
see the rationale section on nicotine replacement therapy (NRT) and other
pharmacological support.
Full details of the evidence and the committee''s discussion are in evidence review J:
nicotine replacement therapies and e-cigarettes in pregnancy: update.
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3 Stop-smoking interventions for under-served groups
How can effective and cost-effective interventions to support people to stop smoking be
modified to improve engagement with and accessibility for under-served groups? How
acceptable are these interventions to these groups? [2021]
For a short explanation of why the committee made the recommendation for research,
see the rationale section on commissioning and designing services.
Full details of the evidence and the committee''s discussion are in evidence review K:
cessation and harm-reduction treatments.
4 Support for people with mental health conditions to stop
smoking
How can people with mental health conditions be supported effectively to stop smoking
(at individual and system level)? What are the challenges and opportunities and how can
they be addressed? [2021]
For a short explanation of why the committee made the recommendation for research,
see the rationale section on stop-smoking support in mental health services.
Full details of the evidence and the committee''s discussion are in evidence review O:
tailored interventions for those with mental health conditions.
5 E-cigarettes and pregnancy
What are the views and concerns of:
? pregnant women who smoke
? the healthcare professionals who care for them
about the use of nicotine-containing e-cigarettes during pregnancy? [2021]
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For a short explanation of why the committee made the recommendation for research,
see the rationale section on nicotine replacement therapy and other pharmacological
support.
Full details of the evidence and the committee''s discussion are in evidence review J:
nicotine replacement therapies and e-cigarettes in pregnancy: update.
Other recommendations for research
6 E-cigarettes for harm reduction
Are nicotine-containing e-cigarettes effective and safe for harm reduction when used
alongside tobacco products to cut down on smoking (dual-use approach)? [2021]
For a short explanation of why the committee made the recommendation for research,
see the rationale section on nicotine-containing e-cigarettes for harm reduction.
Full details of the evidence and the committee''s discussion are in evidence review K:
cessation and harm-reduction treatments.
7 Use of e-cigarettes (amount and frequency)
Does the effectiveness of nicotine-containing e-cigarettes as an aid to stopping smoking
vary according to the amount of nicotine they contain or the frequency of use? [2021]
For a short explanation of why the committee made the recommendation for research,
see the rationale section on advice on nicotine-containing e-cigarettes.
Full details of the evidence and the committee''s discussion are in evidence review K:
cessation and harm-reduction treatments.
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8 E-cigarette flavours
Do the flavours used in nicotine-containing e-cigarettes have an impact on their
effectiveness as an aid to stopping smoking, and are there any adverse effects associated
with them? [2021]
For a short explanation of why the committee made the recommendation for research,
see the rationale section on advice on nicotine-containing e-cigarettes.
Full details of the evidence and the committee''s discussion are in evidence review K:
cessation and harm-reduction treatments.
9 E-cigarettes and established future smoking
Is e-cigarette use in children, young people and young adults who do not smoke
associated with future established smoking? [2021]
For a short explanation of why the committee made the recommendation for research,
see the rationale section on adult-led interventions in schools.
Full details of the evidence and the committee''s discussion are in evidence review F
and G: e-cigarettes and young people.
10 Factors that may influence the use of nicotine replacement
therapy and e-cigarettes
Which factors may prevent people who currently smoke tobacco from using other forms of
nicotine such as NRT and nicotine-containing e-cigarettes? Does this vary according to
population group, particularly among under-served groups? [2021]
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For a short explanation of why the committee made the recommendation for research,
see the rationale section on using stop-smoking interventions.
Full details of the evidence and the committee''s discussion are in evidence review L:
barriers and facilitators to using e-cigarettes for cessation or harm reduction.
11 Relapse prevention
Are NRT or nicotine-containing e-cigarettes effective for preventing relapse after a
successful quit attempt? [2021]
For a short explanation of why the committee made the recommendation for research,
see the rationale section on supporting people trying to stop smoking.
Full details of the evidence and the committee''s discussion are in evidence review N:
smoking relapse prevention.
12 Relapse prevention after enforced, temporary quit
How can people who have recently stopped or temporarily abstained from smoking in a
smokefree inpatient or treatment environment be best supported after discharge to
prevent relapse or to stop permanently? [2021]
For a short explanation of why the committee made the recommendation for research,
see the rationale section on supporting people trying to stop smoking.
Full details of the evidence and the committee''s discussion are in evidence review N:
smoking relapse prevention.
13 Carbon monoxide monitoring
What is the validity of different thresholds of carbon monoxide in exhaled breath as
markers of quitting, based on diagnostic review and modelling? [2018]
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14 Allen Carr''s Easyway
For adults who want to stop smoking, what is the effectiveness and cost effectiveness of
Allen Carr''s Easyway programme delivered in formats other than in-person group seminars
(for example online or using the self-help book) compared with other methods of smoking
cessation? [2022]
For specific groups who are at risk of health inequalities, for example pregnant women,
people from lower socioeconomic backgrounds or people who do not speak English well:
? What is the differential effectiveness and cost-effectiveness of Allen Carr''s Easyway
(including the in-person group seminar and other formats)?
? What strategies or interventions are effective in minimising those differences? [2022]
For a short explanation of why the committee made the recommendations for
research, see the rationale section on stop-smoking interventions.
Full details of the evidence and the committee''s discussion are in evidence review P:
effectiveness and cost-effectiveness of Allen Carr''s Easyway.
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Rationale and impact
These sections briefly explain why the committee made the 2021 recommendations and
how they might affect practice and services. They link to details of the evidence and a full
description of the committee''s discussion.
Adult-led interventions in schools
Recommendations 1.6.3 and 1.6.4
Why the committee made the recommendations
The committee wanted to discourage e-cigarette use among young people and young
adults who do not smoke because evidence shows that use of e-cigarettes is linked with a
higher chance of ever smoking later in life. The committee members agreed that ideas
about smoking and what is normal can start from a young age so the recommendation
should also apply to this age group.
The committee agreed that school-based interventions could help to discourage
e-cigarette use among those who do not smoke.
The committee noted the need to not inadvertently make e-cigarettes desirable. They also
emphasised that e-cigarettes should not be confused with tobacco products, so talking
about them separately is important.
The committee agreed that more evidence is needed about whether e-cigarette use is
linked with habitual smoking (rather than experimental smoking) in the future, the factors
that determine this link, and the levels of e-cigarette use in people under 25 (see the
recommendation for research on e-cigarettes and established future smoking).
How the recommendations might affect practice
Adding information about e-cigarettes to existing curriculum-based interventions to stop
people taking up smoking is a change to current practice, but it should have little resource
impact.
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Return to recommendations
Stop-smoking interventions
Recommendations 1.12.1 to 1.12.8
Why the committee made the recommendations
The committee looked at a large amount of evidence assessing the relative effectiveness
of several interventions, including medicinally licensed products (varenicline, bupropion
and nicotine replacement therapy [NRT]) and nicotine-containing e-cigarettes. They also
looked at these interventions combined with each other. Most of the interventions or
combinations of interventions were delivered with behavioural support. Most evidence
investigated medicinally licensed products, with fewer studies about e-cigarettes.
The evidence found that these interventions were effective, and that some were likely to
be more effective than others, especially in combination with behavioural support. The
committee also agreed with the evidence that a combination of short- and long-acting
NRT was effective as well.
Based on the evidence of relative effectiveness and their expertise, the committee agreed
that several individual products, as well as short-acting and long-acting NRT in
combination, were likely to lead to people successfully stopping smoking when used
alongside behavioural support. The committee agreed that people should first be told
about all the available options so they can make their own choice. If people do want more
information about which options are likely to work best, it is important that people
providing stop-smoking support or advice can make this clear. The committee discussed
very brief advice and using opportunities to tell people who smoke about the range of
interventions available, along with having longer discussions about these options and
providing more detailed advice. They agreed these align well with the principles of NHS
England''s making every contact count and NICE''s making every contact count resources.
The committee looked at the evidence for Allen Carr''s Easyway to stop smoking in-person
group seminars. This is an approach that uses cognitive behavioural therapy and relaxation
methods without pharmacotherapy. It also includes a final ritual cigarette at the end of the
seminar, regular follow-ups and optional shorter follow-up sessions.
The evidence considered by the committee compared Allen Carr''s Easyway in-person
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group seminar with 1-to-1 support provided by an NHS stop smoking service (which
includes behavioural support and the use of medicinally licensed products) and with a
remote stop smoking service (which included behavioural support and information about
how to access medicinally licensed products). The committee agreed the evidence
showed it was as good as other methods such as 1-to-1 support provided by local stop-
smoking services, but there was not enough evidence to position Allen Carr''s Easyway in-
person group seminar within the hierarchy of effectiveness of interventions in
recommendations 1.12.7 or 1.12.8.
The committee noted that evidence suggests Allen Carr''s Easyway in-person group
seminar is cost effective and represents good value for money from an NHS and public
sector perspective. They agreed that making it available through the NHS and local
authorities alongside other interventions would broaden people''s choice, and that the
more choice people have the more likely they are to find the right intervention for them.
They also agreed that some people are reluctant to use pharmacotherapy, and Allen Carr''s
Easyway would potentially increase the number of people attempting to stop smoking by
offering an alternative to interventions that include pharmacotherapy.
The committee discussed various ways of providing the seminar, including online, but
noted that the evidence they saw was only for the in-person group seminar (although in 1
study an online follow up was offered). Therefore they were unable to generalise from this
evidence to formats other than the in-person group seminar.
The committee discussed the funding of studies of the intervention. One was funded by
Allen Carr''s Easyway, but the committee agreed that the methods used to conduct the
study minimised any risk of bias associated with this.
The committee discussed the potential effect of Allen Carr''s Easyway on inequalities in
health. They noted that the length of the seminar (4.5 to 6 hours) and any travel costs to
attend the seminar might be difficult for some people, and that people who are
housebound would not be able to attend an in-person group seminar at all. They also
noted that the evidence did not include any analysis by age, family background, or
pregnancy and so it was not clear whether its effectiveness differed in these groups. The
committee were unaware whether the in-person group seminars were available in
languages other than English, and agreed this was a potential barrier for some people. The
evidence also showed that the quit rate was greater in people with higher education in the
Allen Carr Easyway in-person group seminar arm. The committee discussed that
commissioners would need to know and understand the needs of their local populations to
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be able to commission Allen Carr''s Easyway in a way that would maximise access and use
of the service.
The committee agreed that more research on the effects of Allen Carr''s Easyway in
different population groups, and on the effectiveness of other ways to deliver the
programme (for example the online and book versions) would be useful (see the
recommendations for research on Allen Carr''s Easyway).
The committee decided not to recommend some combinations of interventions even
though they were as effective as individual options. This was because, based on their
experience, they had concerns over adherence rates, the difficulty of obtaining
prescriptions for multiple interventions at once and a lack of information on
contraindications that made these combinations less feasible than other options.
In most of the evidence, the stop-smoking product (medicinally licensed products or
nicotine-containing e-cigarettes) was combined with some form of behavioural support.
This meant that the results of the evidence depended on behavioural support being given
alongside. The committee agreed that people providing stop-smoking support should offer
behavioural support alongside any nicotine-containing products the person is using,
irrespective of whether they are providing the product. This is to give people a better
chance of stopping smoking. They also agreed that offering behavioural support to people
using nicotine-containing e-cigarettes would increase their chances of stopping smoking.
In addition, the committee recognised the need for more evidence about what factors may
prevent those who smoke from using other forms of nicotine, particularly among
population groups with higher smoking prevalence. (See the recommendation for research
on factors that may influence the use of nicotine replacement therapy and e-cigarettes.)
How the recommendations might affect practice
Conversations guided by each person''s preference are good practice and should already
be taking place. However, extra time may be needed for people providing stop-smoking
support or advice to discuss the intervention options with people who want to stop
smoking, especially for the additional advice on e-cigarettes. If these recommendations
lead people to quit successfully with fewer unsuccessful attempts, this may mean fewer
appointments per person.
Commissioning Allen Carr''s Easyway in-person group seminar through the NHS or local
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authority would have resource implications for stop smoking services. But the intervention
is cost effective and although the initial cost was higher than the comparator (Quit.ie or
local stop smoking services group) this would be quickly offset (within 5 to 7 years) by the
reduction in comorbidities and associated healthcare costs. The committee were also
advised that the NHS or local authority is likely to be able to negotiate a discount for the
intervention if enough people take up the offer.
The committee noted that some people living in rural areas may need help with travel
costs if they need to travel long distances to attend the in-person seminar.
Return to recommendations
Advice on nicotine-containing e-cigarettes
Recommendations 1.12.13 to 1.12.17
Why the committee made the recommendations
Evidence showed that nicotine-containing e-cigarettes can help people to stop smoking
and are of similar effectiveness to other cessation options such as varenicline or long-
acting and short-acting NRT.
Benefits and harms of e-cigarettes
The extensive harms of smoking are well known, and the committee agreed it is unlikely
that e-cigarettes could cause similar levels of harm. But they also agreed that for people
who do not smoke, it is unlikely that inhaling vapour from an e-cigarette is as low risk as
not doing so, although the extent of that risk is not yet known. They discussed the
potential benefits and risks of using nicotine-containing e-cigarettes to stop smoking.
There was a small amount of evidence about short-term adverse events of e-cigarettes
that did not show that they caused any more adverse events than NRT, e-cigarettes
without nicotine or no treatment. The committee had low confidence in this evidence
because studies were usually designed to investigate effectiveness and not adverse
events, meaning they may not have been large enough to show an effect.
There were only 2 studies about the long-term harms of using nicotine-containing
e-cigarettes, and the committee discussed the uncertainty of the evidence and their
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concerns with these studies. A call for evidence did not produce any additional evidence in
this area.
The committee agreed that there is insufficient evidence to tell whether e-cigarettes
cause long-term effects. E-cigarettes are relatively new devices, and it is important to
understand whether they cause any health harms or benefits aside from their potential to
reduce smoking-related harm (see the recommendation for research on health effects of
e-cigarettes).
The committee recognised the need for evidence about what factors may influence use of
e-cigarettes. So they made recommendations for research relating to any possible impacts
of the amount of nicotine and frequency of use, and flavourings.
The committee discussed the outbreak of serious lung disease in the US in 2019, which US
authorities identified was largely caused by vaping cannabis products containing vitamin E
acetate. They also noted there has been a Medicines and Healthcare products Regulatory
Agency (MHRA) Drug Safety Update highlighting serious lung injury with e-cigarettes
issued in January 2020 (E-cigarette use or vaping: reporting suspected adverse reactions,
including lung injury). The committee discussed that the UK has well-established
regulations for e-cigarettes that restrict what they can contain.
Experts from the MHRA described to the committee the monitoring process for both short-
and long-term harms of using e-cigarettes. Monitoring is ongoing and the evidence may
change in the future, but the committee was not aware of any major concerns being
identified. Accurate information relies on adverse events being reported, so the committee
recommended that people providing stop-smoking support or advice should actively
report any suspected adverse events and encourage people to report any that they
experience.
The committee used their knowledge and experience to supplement the very limited and
uncertain evidence about harms. They agreed that because many of the harmful
components of cigarettes are not present in e-cigarettes, switching to nicotine-containing
e-cigarettes was likely to be significantly less harmful than continuing smoking. So, the
committee agreed that people should be able to access them as part of the range of
interventions they can choose to use (see the section on stop-smoking interventions).
They also agreed that people should be given up-to-date information on what is known
about e-cigarettes to help them make an informed decision about whether to use them.
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The committee agreed that with the limited data on effects of longer-term use, people
should only use e-cigarettes for as long as they help prevent them going back to smoking.
They also agreed that people should be discouraged from continuing to smoke when using
e-cigarettes, even if they are smoking less, because there is no information on whether
this will reduce their harm from smoking.
The committee discussed that it is more likely that people will not get enough nicotine to
help them stop smoking, than get too much. They agreed that not getting enough nicotine
is likely to increase the risk that the person will return to smoking, so they recommended
that people should be encouraged to use as much as they need and told how to use the
products effectively.
How the recommendations might affect practice
Extra time may be needed to discuss e-cigarettes with people who are interested in using
them. If these recommendations lead to more successful quit attempts, this may mean
fewer appointments per person and substantial savings in downstream costs associated
with smoking.
Return to recommendations
Stop-smoking support in mental health services
Recommendation 1.14.19
Why the committee made the recommendation
The committee agreed the importance of stop-smoking support being available to all, and
that people with mental health conditions should not be treated differently in this.
However, because those with mental health conditions have a higher prevalence of
smoking, and are less likely to access standard smoking cessation services and have lower
quit rates, it is important to look at whether additional support could be appropriate.
There was a small amount of evidence about tailored smoking cessation interventions for
people with mental health conditions. The evidence of effectiveness identified was in
populations with severe mental health conditions such as bipolar disorder, schizophrenia
or post-traumatic stress disorder. However, the committee noted there was a lack of
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consensus of what constitutes a severe mental health condition. They heard from experts
that people with other mental health conditions may need additional support as well. This
applies both at an individual level and, for those in mental health settings, at a system
level. The committee agreed that additional support should be offered to people with
severe mental health conditions, and although it might be considered for other people with
mental health conditions, there was insufficient evidence to make a wider
recommendation. The committee noted that the recommended additional support would
fit with current stop-smoking provision. Furthermore, the committee identified this as an
important research gap that needs to be addressed to reduce health inequalities (see the
recommendation for research on support for people with mental health conditions to stop
smoking).
How the recommendation might affect practice
This potential additional support may need extra time and additional appointments. If
these recommendations lead to more successful quit attempts, this may mean fewer
appointments per person and substantial savings in downstream costs associated with
smoking.
Return to recommendations
Nicotine-containing e-cigarettes for harm
reduction
Recommendation for research 6
Why the committee made the recommendation for research
No evidence was found on the use of e-cigarettes specifically for harm reduction for
people who do not want, or are not ready, to stop smoking in one go. So, the committee
chose not to make recommendations on using e-cigarettes for harm reduction. They did
discuss that e-cigarettes may be used in this way and that there may be substantial dual
use; that is, when someone is both smoking and using e-cigarettes.
The committee agreed that more information is needed about the use of e-cigarettes for
those who may wish to reduce the amount they smoke.
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Return to the recommendation for research
Supporting people trying to stop smoking
Recommendations 1.17.1 and 1.17.2
Why the committee made the recommendations
The committee agreed that strategies to avoid relapsing are an important part of stop-
smoking advice and support, and are likely to be most effective when introduced early in
the process and regularly revisited.
Evidence about NRT for preventing relapse was mixed. Although there was evidence that
they may be effective in people who had recently quit, using a single type of fast-acting
NRT did not reduce relapse with any certainty when people had stopped smoking for
longer. The committee discussed this evidence and noted that in their experience, using
NRT for longer can stop people relapsing to smoking, particularly if more than 1 type of
NRT is used (usually combining patches with a fast-acting form of NRT). They discussed
that only offering NRT for 12 weeks could cause people to relapse.
Evidence showed that if people who have used varenicline and bupropion to stop smoking
continue taking it for longer, this improves their chances of staying stopped. This included
people diagnosed with serious mental illness. There were a small number of studies and
they investigated different groups of people and used varenicline in different ways, so the
committee had some uncertainty about the evidence.
The committee reflected on the mixed findings from the evidence. They agreed that,
because preventing relapse is so important for people who have been able to stop
smoking, offering longer-term pharmacotherapy to help prevent relapse was reasonable.
The committee noted that bupropion was not licensed for relapse prevention. The studies
that evaluated bupropion for this indication had different dosing regimens, so the
committee did not specify what dose or duration of bupropion was most effective for
preventing relapse.
The committee recognised the need for more evidence about which nicotine-containing
products or combination of products are best at preventing relapse after a successful quit
attempt (see the recommendations for research on relapse prevention and relapse
prevention after enforced, temporary quit).
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How the recommendations might affect practice
Stop-smoking advisers can use existing appointments to provide information about
preventing relapse to people who want to stop smoking, so this is not expected to have a
resource impact, though there may costs associated with prescribing additional
pharmacotherapies.
Return to recommendations
Reviewing the approach for people trying to stop
smoking, cutting down or stopping temporarily
Recommendations 1.17.6 and 1.17.7
Why the committee made the recommendations
The committee discussed that it is important to review any stop-smoking or harm-
reduction approach taken so that any problems can be addressed. They agreed that it can
take someone multiple attempts to stop smoking for good. Encouraging people who have
relapsed to smoking and talking to them about trying again may mean that they stay in
touch with the service and are more likely to stop smoking in the long term.
How the recommendations might affect practice
Stop-smoking advisers can use existing appointments to discuss with people the
approach they are taking and future attempts to stop or reduce harm from smoking, so this
is not expected to have a resource impact.
Return to recommendations
Identifying pregnant women who smoke and
referring them for stop-smoking support
Recommendations 1.18.1 to 1.18.3
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Why the committee made the recommendations
Stopping smoking in pregnancy is important for the health of both the woman and her
baby.
Existing recommended practice, based on NICE''s previous guideline on stopping smoking
in pregnancy and after childbirth, is to offer opt-out provision for pregnant women. The
evidence about opt-out referral systems was mixed, but the most recent evidence showed
that it resulted in higher self-reported quit rates and more engagement with stop-smoking
support.
Most current evidence uses carbon monoxide levels of 4 parts per million (ppm) as the
cut-off for referral. Based on this and their expertise, the committee recommended that a
carbon monoxide reading of 4 ppm or above would be an appropriate level to
automatically refer women for stop-smoking support. This also aligns with the NHS Saving
Babies'' Lives Care Bundle.
The evidence about women''s views on opt-out referral showed that giving women
information on carbon monoxide testing and the automatic referral was an important factor
in whether they accepted the referral and took up the support. The committee discussed
whether there was a specific need for a recommendation on giving information, because
all clinical treatment pathways should ensure that people are fully informed and take an
active part in their care. They agreed that a recommendation would be helpful in this case,
because they considered opt-out treatment is not common in most areas of care.
During development of this guideline, carbon monoxide monitoring was not being used
because of COVID-19 practice changes. The committee acknowledged that during the
COVID-19 pandemic referral decisions may need to be made without using carbon
monoxide monitoring.
How the recommendations might affect practice
The recommendations reflect current widespread practice and so should have little
resource impact.
Return to recommendations
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Nicotine replacement therapy and other
pharmacological support
Recommendations 1.20.6 to 1.20.8 and 1.20.10
Why the committee made the recommendations
NICE''s 2010 guideline on stopping smoking in pregnancy and after childbirth (replaced by
this guideline) recommended nicotine replacement therapy (NRT) for pregnant women
only if they are not able to stop smoking using a behavioural intervention without NRT, and
once they have stopped smoking. New evidence showed that NRT may help women stop
smoking in pregnancy when added to a behavioural intervention.
The committee discussed that women may stop smoking temporarily during pregnancy
and relapse afterwards. There was no evidence about continuing NRT after pregnancy to
prevent this but, based on their expert opinion, the committee agreed it may be useful.
Evidence showed that advice from healthcare professionals, particularly midwives, was
valuable to pregnant women and contributed to their decisions about using NRT. The
evidence also showed that consistent advice addressing the main concerns women tend
to have about NRT during pregnancy (such as addictiveness, potential side effects and
any pregnancy impacts) may help women to feel comfortable using NRT during and after
pregnancy.
We found no evidence about the effectiveness or safety of using nicotine-containing
e-cigarettes to help women stop smoking in pregnancy. Many of the studies in the
effectiveness meta-analysis for nicotine replacement therapies were over 10 years old and
most used doses of nicotine that would now be considered to be low. The committee
therefore made recommendations for research to help understand what type and dose of
NRT is most effective and the views and concerns of pregnant women and their
healthcare professionals about using nicotine-containing e-cigarettes in pregnancy.
How the recommendations might affect practice
The change in recommendations since NICE''s previous guideline may increase
prescriptions of NRT to pregnant women, and potentially increase how long it is prescribed
for. If this leads to more cases of successful quitting, it will create considerable savings
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downstream.
Return to recommendations
Incentives to stop smoking
Recommendations 1.20.12 to 1.20.14
Why the committee made the recommendations
Evidence showed that offering financial incentives to help pregnant women stop smoking
was both effective and cost effective. Voucher incentives were acceptable to many
pregnant women and healthcare providers. The committee noted that these are already
being used in some areas.
The committee discussed and agreed with the evidence that ''contingent rewards'' (given
only if biochemical tests prove the woman has stopped) were more effective than
guaranteed payments given whether the woman has stopped or not.
More evidence is needed to find out what value of incentive works best. Evidence from the
UK showed that schemes in which around ￡400 could be gained in vouchers staggered
over time (with reductions for each relapse made) were effective and cost effective, so the
committee included this amount as a guide.
Based on the evidence and their expertise, the committee agreed that incentive schemes
that include both the pregnant woman and a significant other supporter could have a
better chance of success.
They also agreed that some staff may be unfamiliar with incentive schemes and would
benefit from training to help deliver them.
Although the guideline recommends that vouchers should be provided only to those with
an abstinence validated by a biochemical method, the committee acknowledged that
during the COVID-19 pandemic carbon monoxide validation may not be being used. While
this is the case, vouchers are recommended even if biochemical validation using carbon
monoxide is not possible.
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How the recommendations might affect practice
Incentive schemes are already used in some areas. Areas that do not already use them will
need staff time to run them, and financial resources to award the vouchers. Training for
people promoting and delivering the incentive schemes may need resources.
Return to recommendations
Commissioning and designing services
Recommendations 1.22.1 and 1.22.2
Why the committee made the recommendations
The committee looked at a large amount of evidence assessing the relative effectiveness
of interventions for stopping smoking (medicinally licensed products and nicotine-
containing e-cigarettes, alone or in combination). Most of the interventions or
combinations of interventions were delivered with behavioural support. The committee
agreed which interventions should be accessible (see the rationale and impact section for
stop-smoking interventions). They agreed that the recommendation from NICE''s 2018
guideline on stop-smoking interventions and services (replaced by this guideline) to make
stop-smoking interventions available through local plans and approaches to health and
wellbeing was still relevant, so they drew on that to make a new recommendation.
The committee noted that not all medicinally licensed products are available in all stop-
smoking services, and so local arrangements are in place to ensure that these are
accessible when needed. Nicotine-containing e-cigarettes are not licensed medicines so
cannot currently be provided on prescription. However, there are ways of increasing their
accessibility, for example by giving evidence-based advice about them and information on
where people can access them. The committee were aware that some services use
vouchers or starter pack schemes.
Based on evidence and their experience of the use of NRT for preventing relapse, the
committee recommended it for longer-term use (see the rationale and impact section for
supporting people trying to stop smoking) and agreed this needed to be reflected in
service specifications to make sure it was made available.
The committee heard from experts that smoking prevalence is high in some population
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groups that may not be well served by existing stop-smoking provision (such as those with
mental health conditions, or those who identify as LGBT+, or those with low income). And
that although these groups may be motivated to stop smoking, they may experience
additional challenges to successfully stopping (see the equality impact assessment).
We did not find any evidence on how to tailor effective and cost-effective interventions to
ensure that they are engaging and accessible for under-served groups, or how acceptable
those interventions may be for those groups. The committee identified this as an
important gap that needs to be addressed to reduce health inequalities (see the
recommendation for research on stop-smoking interventions for under-served groups).
How the recommendations might affect practice
The committee noted that schemes are already in place in some areas to support starting
the use of nicotine-containing e-cigarettes for stopping smoking.
NICE''s 2013 guideline on smoking harm reduction already recommended that service
specifications require providers of stop-smoking support to offer long-term NRT.
Return to recommendations
Stop-smoking support in secondary care
Recommendation 1.22.14
Why the committee made the recommendation
The committee agreed that nicotine-containing products should be available for sale in
secondary care settings to help people stop smoking and to support temporary
abstinence for patients, staff and visitors because hospital grounds are covered by
smokefree legislation.
How the recommendation might affect practice
Making the full range of effective options available for sale may be a change to current
practice, but it is not expected to have a large impact on resources.
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Return to recommendations
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Context
In 2018, 14.7% of adults in the UK smoked cigarettes. Rates were higher than average for
some groups, including those in routine and manual occupations, and those with mental
health conditions. Although this is a decline of more than 5 percentage points since 2011,
smoking is still the main cause of preventable illness and premature death in England
(Office for National Statistics [2018] Adult smoking habits in the UK). In 2017/2018, an
estimated 4% (489,300) of NHS hospital admissions in England, and an estimated 16%
(77,800) of all deaths, were attributed to smoking (NHS Digital 2019 Statistics on smoking,
England).
Treating smoking-related illness is estimated to cost the NHS ￡2.6 billion a year and the
wider cost to society is around ￡11 billion a year (NHS England Health matters: tobacco
and alcohol CQUIN).
In 1 in 5 local authorities, the specialist service has been replaced by an integrated lifestyle
service (Action on Smoking and Health and Cancer Research UK''s Stepping up: the
response of stop smoking services in England to the COVID-19 pandemic).
This guideline forms a single source for tobacco guidance that updates and replaces
NICE''s guidelines on:
? smoking: workplace interventions (PH5, 2007)
? smoking: preventing uptake in children and young people (PH14, 2008)
? smoking prevention in schools (PH23, 2010)
? smoking: stopping in pregnancy and after childbirth (PH26, 2010)
? smokeless tobacco: South Asian communities (PH39, 2012)
? smoking: harm reduction (PH45, 2013)
? smoking: acute, maternity and mental health services (PH48, 2013)
? stop-smoking interventions and services (NG92, 2018).
This guideline includes recommendations on harm reduction, which was previously
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covered by PH45. In PH45, harm reduction included cutting down before stopping
smoking, cutting down longer term, temporary abstinence, or stopping smoking altogether
by switching to a medicinally licensed nicotine-containing product. In the current guideline,
switching completely from smoking to any nicotine-containing product is considered to be
stopping smoking rather than harm reduction.
The approaches for harm reduction in this guideline should not detract from providing the
highly cost-effective interventions to help people stop smoking altogether. Instead,
recommendations on harm reduction are intended to support and extend the reach and
impact of existing stop-smoking support. Although existing evidence is not clear about the
health benefits of smoking reduction, people who reduce the amount they smoke are more
likely to stop smoking eventually.
This guideline was developed between 2019 and 2021. There has not been anything
published to date on COVID-19 that the committee considered to have an impact on this
guideline. We have highlighted in the rationale sections any recommendations that are
affected by temporary changes in practice because of COVID-19. The committee further
noted that some stop-smoking support may now be being delivered by phone or video
rather than face to face, but this is not stopping the services from being delivered.
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Finding more information and committee
details
To find NICE guidance on related topics, including guidance in development, see the NICE
topic page on smoking and tobacco.
For full details of the evidence and the guideline committee''s discussions, see the
evidence reviews. You can also find information about how the guideline was developed,
including details of the committee.
NICE has produced tools and resources to help you put this guideline into practice. For
general help and advice on putting our guidelines into practice, see resources to help you
put NICE guidance into practice.
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Update information
January 2023: We have amended the recommendation on carbon monoxide testing at
antenatal appointments to reduce the number of tests for women with low carbon
monoxide readings and no history of smoking, in line with new NHS England guidance.
This recommendation is marked [2023].
August 2022: We have reviewed the evidence on Allen Carr''s Easyway to stop smoking in-
person seminar for people who smoke.
Recommendations updated as a result of this review are marked [2021, amended 2022].
November 2021: This guideline updates and replaces NICE''s guidelines on:
? smoking: workplace interventions (PH5, 2007)
? smoking: preventing uptake in children and young people (PH14, 2008)
? smoking prevention in schools (PH23, 2010)
? smoking: stopping in pregnancy and after childbirth (PH26, 2010)
? smokeless tobacco: South Asian communities (PH39, 2012)
? smoking: harm reduction (PH45, 2013)
? smoking: acute, maternity and mental health services (PH48, 2013)
? stop-smoking interventions and services (NG92, 2018).
We have reviewed the evidence and made new recommendations, if relevant, on:
? digital and mass-media stop-smoking campaigns for preventing uptake
? proxy purchasing and supply of illicit tobacco
? impact of e-cigarettes on future smoking behaviour
? Smokefree Class Competitions for preventing uptake (no recommendations made)
? opt-out referral to stop-smoking support in pregnancy
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? incentives for stopping smoking in pregnancy
? effectiveness, safety and acceptability of nicotine replacement therapy and
e-cigarettes for stopping smoking in pregnancy
? effectiveness of treatments for stopping smoking
? barriers and facilitators to using e-cigarettes for stopping smoking
? long-term health effects of using e-cigarettes
? relapse prevention.
These recommendations are marked [2021].
We have also made some changes without an evidence review (marked as amended 2021)
to:
? avoid duplicating other NICE guidance, and remove duplication or improve alignment
between recommendations from different guidelines
? remove any recommendations about providing information or tailoring support and
treatment that overlap with the general principles in NICE''s guideline on patient
experience in adult NHS services
? remove prevention strategies that are no longer standard practice or considered
appropriate, particularly fear-based messaging for children and young people
? change the emphasis of prevention campaigns to support policy rather than
enforcement
? remove mention of the ASSIST (A Stop Smoking in Schools Trial) intervention, because
current evidence has not been evaluated
? clarify who should be taking action
? clarify where mention of health problems relates specifically to smoking-related
problems
? reflect uncertainty about the impact of long-term use of licensed nicotine-containing
products
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? clarify expected minor side effects from stopping smoking, so these are not mistaken
for effects of licensed nicotine-containing products or other interventions
? clarify what interventions were intended to be used in recommendations that
previously talked about ''pharmacotherapies''
? clarify reasons for monitoring prescribed medicines in people who are stopping or
trying to stop smoking
? remove mention of people in custodial settings, because these are now all smokefree.
For more information about how the original guidelines were amalgamated and any
changes that were made to the recommendations, see the summary of deleted and
amended recommendations.
ISBN: 978-1-4731-4971-7
Accreditation
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