Quality standard
Quality statement 2: Advice
Quality statement 2: Advice
Rationale
People who smoke or use smokeless tobacco should be advised to stop in a way that is sensitive to their preferences and needs. It is important to explain that support is available to help them quit and offer support and treatment if the person wants this or ensure that the person knows where they can find support in the future.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly. Some localities may want to focus on equality of care depending on local needs, for example, by assessing care for particular socioeconomic or ethnic groups.
Structure
Evidence that health and social care professionals undergo training to give advice on how to quit using tobacco.
Data source: Data on training to deliver advice on quitting smoking or smokeless tobacco can be recorded from information recorded locally by health and social care professionals and provider organisations, for example from staff competency records. The National Centre for Smoking Cessation and Training have training resources containing information on delivery of advice on the most effective way of quitting.
Process
The following process measure denominator uses a key point of contact for measurement purposes only.
Proportion of people attending a key point of contact and reporting current smoking or use of smokeless tobacco, who receive advice on quitting.
Numerator – the number in the denominator who receive advice on quitting.
Denominator – the number of people attending a key point of contact who report current smoking or use of smokeless tobacco.
Data source: Data on receipt of advice on quitting smoking or smokeless tobacco can be collected from information recorded locally by health and social care professionals and provider organisations, for example from patient records.
The Quality Outcomes Framework indicator SMOK004 reports the percentage of patients aged 15 or over who are recorded as current smokers who have a record of an offer of support or treatment within the preceding 24 months. This offer of support includes brief intervention and smoking cessation education. The British Thoracic Society's national smoking cessation audit collects data on evidence of provision of very brief advice for current smokers from inpatient medical records.
Outcome
a) Quit rates.
Data source: NHS Digital's statistics on NHS stop smoking services in England collects and reports data on people who smoke setting a quit date with an NHS stop-smoking service including self-reported and carbon monoxide-validated quit rates. No routinely collected national data for this measure has been identified for quit rates outside of NHS stop-smoking services. Quit rates can be collected from information recorded locally by healthcare professionals and provider organisation, for example from patient records.
Self-reported quit rates for people who use smokeless tobacco can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
b) Smoking prevalence.
Data source: NHS Digital's statistics on smoking – England reports smoking prevalence among young people aged between 11 and 15 years. Public Health Outcomes Framework 2019 to 2022 (Public Health Outcome Indicators 2019) includes indicators on smoking prevalence in 15 year olds (indicator number 2.09) and smoking prevalence in adults (indicator number 2.14).
What the quality statement means for different audiences
Service providers (for example, primary care services, secondary care services and social care services) ensure that systems are in place for people who smoke or use smokeless tobacco and want to stop to be provided with advice on how to quit. They ensure that health and social care professionals receive training to deliver advice on quitting smoking and smokeless tobacco.
Health and social care professionals (such as GPs, nurses, doctors, allied health professionals, healthcare support workers, maternity support workers and social workers) are trained to deliver advice on quitting smoking and smokeless tobacco, and provide it in a way that is sensitive to the person's preferences and needs. They are aware of local referral pathways to tobacco cessation services and can refer people if needed.
Commissioners (for example, local authorities and integrated care systems) ensure that they commission services that can provide advice on quitting smoking and smokeless tobacco. They commission training on delivery of advice on quitting smoking and, if local needs assessment shows that it is necessary, they commission training and a range of services to help South Asian people stop using smokeless tobacco.
People who smoke or use smokeless tobacco are advised about the best way to quit and how they can be supported to do this. This should be provided in a way that is sensitive to their preferences and needs.
Source guidance
Tobacco: preventing uptake, promoting quitting and treating dependence. NICE guideline NG209 (2021, updated 2022), recommendations 1.11.2, 1.11.4, 1.12.7, 1.13.1 and 1.16.6
Definitions of terms used in this quality statement
Tobacco
Includes smoked tobacco, such as cigarettes and shisha, and smokeless tobacco.
Smokeless tobacco is any product containing tobacco that is placed in the mouth or nose and not burned. It 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:
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Tobacco with or without flavourants: misri India tobacco (powdered) and qimam (kiman).
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Tobacco with various alkaline modifiers: khaini, naswar (niswar, nass) and gul.
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Tobacco with slaked lime as an alkaline modifier and areca nut: gutkha, zarda, mawa, manipuri and betel quid (with tobacco).
[Adapted from NICE's guideline on tobacco, terms used in this guideline (smokeless tobacco), final scope (2018) and expert opinion]
Advice on quitting
People who smoke should be advised that stopping smoking in one go is the best approach. Advice should be provided in a way that is sensitive to the person's preferences and needs and should include information on how stop-smoking support and treatment can help. There should be a discussion about any stop-smoking aids that the person has used before, and advice given on using nicotine-containing products including nicotine replacement therapy and nicotine-containing e-cigarettes, and medication licensed for smoking cessation. Consider nicotine replacement therapy alongside behavioural support to help women stop smoking in pregnancy and for young people aged 12 and over who are smoking and dependent on tobacco. Varenicline, when available, and bupropion should not be offered to pregnant or breastfeeding women or people under 18.
In August 2022, varenicline was unavailable in the UK. See the MHRA alert on varenicline.
People who use smokeless tobacco should have the health risks explained to them and should be advised to quit using a brief intervention. This involves discussion, negotiation or encouragement. It is carried out when the opportunity arises, typically taking no more than a few minutes for basic advice. [Adapted from NICE's guideline on tobacco, recommendations 1.11.2 to 1.11.4, 1.12.3, 1.12.4, 1.12.7, 1.16.2, 1.20.6 and 1.20.11 and NICE's glossary (brief intervention)]
Key points of contact
Such as:
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a consultation with a newly registered patient
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a consultation about a condition related to smoking or use of smokeless tobacco
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an antenatal appointment
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a dental appointment
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an NHS health check
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an annual review
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a preoperative appointment
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during an inpatient episode
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an outpatient appointment
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at presentation at an emergency department
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at first contact with social care services
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as part of a Care Act assessment
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at presentation after not being in regular contact with a health and social care professional.
[Expert opinion]
Equality and diversity considerations
People who use tobacco should be given advice that they can easily understand themselves, or with support, so they can communicate effectively with health and social care services. Advice should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate and age appropriate. People should have access to an interpreter or advocate if needed.
Smokeless tobacco is predominantly used by people from a South Asian family background. People should be asked if they use smokeless tobacco using the names that the various products are known by locally. If necessary, visual aids should be used to show them what the products look like. People who use smokeless tobacco should be referred to specialist tobacco cessation services, including services specifically for South Asian groups where they are available. These services should take into account the needs of different South Asian communities, for example, by using staff with relevant language skills or translators and by providing translated materials or resources in a non-written format.
For people with additional needs related to a disability, impairment or sensory loss, communication support should be provided as set out in NHS England's Accessible Information Standard or the equivalent standards for the devolved nations.