Recommendations

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.

For recommendations for women who are pregnant or planning a pregnancy, and mothers of infants and young children, and their families see NICE's guideline on smoking: stopping in pregnancy and after childbirth.

For people with cardiovascular or respiratory disease who smoke, see also recommendations 1, 7 and 9 in NICE's guideline on smoking: acute, maternity and mental health services.

1.1 Commissioning and providing stop smoking interventions and services to meet local needs

These recommendations are for commissioners and managers of stop smoking services.

1.1.1 Use sustainability and transformation plans, health and wellbeing strategies, and any other relevant local strategies and plans to ensure evidence-based stop smoking interventions and services are available for everyone who smokes (see recommendation 1.3.1). [2018]

1.1.2 Use Public Health England's public health profiles to estimate smoking prevalence among the local population. [2018]

1.1.3 Prioritise specific groups who are at high risk of tobacco-related harm. These may include:

See how the committee made recommendations 1.1.1 to 1.1.3.

1.2 Monitoring stop smoking services

These recommendations are for commissioners and managers of stop smoking services.

1.2.1 Set targets for stop smoking services, including the number of people using the service and the proportion who successfully quit smoking. Performance targets should include:

  • treating at least 5% of the estimated local population who smoke each year

  • achieving a successful quit 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]

1.2.2 Check self-reported abstinence using carbon monoxide monitoring, with success defined as less than 10 parts per million (ppm) at 4 weeks after the quit date. This does not imply that treatment should stop at 4 weeks. [2018]

1.2.3 Monitor performance data for stop smoking services routinely and independently. Make these results publicly available. [2018]

1.2.4 Audit exceptional results (for example, 4-week quit rates lower than 35% or above 70%) to determine the reasons for unusual performance as well as to identify best practice and ensure it is being followed. [2018]

See how the committee made recommendations 1.2.1 to 1.2.4.

1.3 Evidence-based stop smoking interventions

These recommendations are for commissioners and providers of stop smoking support.

1.3.1 Ensure the following evidence-based interventions are available for adults who smoke:

1.3.2 Consider text messaging as an adjunct to behavioural support. [2018]

1.3.3 Offer varenicline as an option for adults who want to stop smoking, normally only as part of a programme of behavioural support, in line with NICE's technology appraisal guidance on varenicline. [2018]

1.3.4 For adults, prescribe or provide varenicline, bupropion or NRT before they stop smoking. [2018]

1.3.5 Agree a quit date set within the first 2 weeks of bupropion treatment and within the first 1 to 2 weeks of varenicline treatment. Reassess the person shortly before the prescription ends. [2018]

1.3.6 Agree a quit date if NRT is prescribed. Ensure that the person has NRT ready to start the day before the quit date. [2018]

1.3.7 Consider NRT[3] for young people over 12 who are smoking and dependent on nicotine. If this is prescribed, offer it with behavioural support. [2018]

1.3.8 Ensure behavioural support is provided by trained stop smoking staff (see the National Centre for Smoking Cessation and Training [NCSCT] training standard). [2018]

1.3.9 Ensure very brief advice is delivered according to the NCSCT training module on very brief advice. [2018]

See how the committee made recommendations 1.3.1 to 1.3.9.

1.4 Engaging with people who smoke

These recommendations are for health and social care workers in primary and community settings.

1.4.1 At every opportunity, ask people if they smoke and advise them to stop smoking in a way that is sensitive to their preferences and needs. [2018]

1.4.2 Encourage people being referred for elective surgery to stop smoking before their surgery. Refer them to local stop smoking support. [2018]

1.4.3 Discuss any stop smoking aids the person has used before, including personally purchased nicotine-containing products (see recommendations 1.4.4 and 1.5.1). [2018]

1.4.4 Offer advice on using nicotine-containing products on general sale, including NRT and nicotine-containing e‑cigarettes. [2018]

See also recommendations 1, 7 and 9 in NICE's guideline on smoking: acute, maternity and mental health services.

See how the committee made recommendations 1.4.1 to 1.4.4.

1.5 Advice on e‑cigarettes

These recommendations are for health and social care workers in primary and community settings.

1.5.1 For people who smoke and who are using, or are interested in using, a nicotine-containing e‑cigarette on general sale to quit smoking, explain that:

  • although these products are not licensed medicines, they are regulated by the Tobacco and Related Products Regulations 2016

  • many people have found them helpful to quit smoking cigarettes

  • people using e‑cigarettes should stop smoking tobacco completely, because any smoking is harmful

  • the evidence[4] suggests that e‑cigarettes are substantially less harmful to health than smoking but are not risk free

  • the evidence in this area is still developing, including evidence on the long-term health impact. [2018]

See how the committee made recommendation 1.5.1.

1.6 If a person who smokes wants to quit

These recommendations are for health and social care workers in primary and community settings.

1.6.1 Refer people who want to stop smoking to local stop smoking support. [2018]

1.6.2 Discuss how to stop smoking with people who want to quit (the NCSCT programmes explain how to do this). [2018]

1.6.3 Set out the pharmacotherapy and behavioural options as listed in recommendation 1.3.1, taking into consideration previous use of stop smoking aids, and the adverse effects and contraindications of the different pharmacotherapies. [2018]

1.6.4 Explain that a combination of varenicline and behavioural support or a combination of short-acting and long-acting NRT are likely to be most effective. [2018]

1.6.5 If people opt out of a referral to local stop smoking support, refer them to a professional who can offer pharmacotherapy and very brief advice. [2018]

1.6.6 Agree the approach to stopping smoking that best suits the person's preferences. Review this approach at future visits. [2018]

See how the committee made recommendations 1.6.1 to 1.6.6.

1.7 If a person who smokes is not ready to quit

These recommendations are for health and social care workers in primary and community settings.

1.7.1 If people are not ready to stop smoking:

  • make sure they understand that stopping smoking reduces the risks of developing smoking-related illnesses or worsening conditions affected by smoking

  • ask them to think about adopting a harm reduction approach (see NICE's guideline on smoking: harm reduction)

  • encourage them to seek help to quit smoking completely in the future

  • record the fact that they smoke and at every opportunity ask them about it again in a way that is sensitive to their preferences and needs. [2018]

See how the committee made recommendation 1.7.1.

1.8 Telephone quitlines

1.8.1 Ensure publicly sponsored telephone quitlines offer a rapid, positive and authoritative response. If possible, callers whose first language is not English should have access to information and support in their chosen language. [2008]

1.8.2 All staff should receive smoking cessation training (at least in brief interventions to help people stop smoking). [2008]

1.8.3 Staff who offer counselling should be trained to the NCSCT Standard (individual behavioural counselling) and preferably hold an appropriate counselling qualification. Training should comply with the Standard for training in smoking cessation treatments or its updates. [2008, amended 2018]

1.9 Education and training

Local stop smoking services

1.9.1 Ensure training and continuing professional development is available for all those providing stop smoking advice and support. [2008]

1.9.2 Ensure training complies with the NCSCT training standard or its updates. [2008, amended 2018]

Healthcare workers and others who advise people how to quit smoking

1.9.3 Train all frontline healthcare staff to offer very brief advice on how to stop smoking in accordance with recommendations 1.6.2 and 1.6.5. Also train them to make referrals, if necessary and possible, to local stop smoking services. [2008, amended 2018]

1.9.4 Ensure training on how to support people to stop smoking is part of the core curriculum for healthcare undergraduates and postgraduates. [2008]

1.9.5 Provide additional, specialised training for those working with specific groups, for example people with mental health problems and pregnant women who smoke. [2008]

1.9.6 Encourage and train healthcare professionals to ask people about smoking and to advise them of the dangers of exposure to secondhand smoke. [2008]

For recommendations for secondary care providers see NICE's guideline on smoking: acute, maternity and mental health services.

1.10 Campaigns to promote awareness of local stop smoking services

1.10.1 Coordinate communications strategies to support the delivery of stop smoking services, telephone quitlines, school-based interventions, tobacco control policy changes and any other activities designed to help people to stop smoking. [2008]

1.10.2 Develop and deliver communications strategies in partnership with the NHS, regional and local government and 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' quit messages that are non-judgemental, empathetic and respectful, for example 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.

  • Consider targeting and tailoring campaigns towards low income and some minority ethnic groups to address inequalities. [2008, amended 2018]

For recommendations on campaigns for secondary care providers see recommendation 12 in NICE's guideline on smoking: acute, maternity and mental health services.

1.11 Closed institutions

1.11.1 Develop a policy, using guidance provided by the Department of Health and Social Care, to ensure effective stop smoking interventions are provided and promoted in prisons, military establishments and long-stay health centres, such as mental healthcare units. [2008]

See also NICE's guidelines on smoking: workplace interventions, smoking: acute, maternity and mental health services and recommendations 9 and 10 in NICE's guideline on smoking: harm reduction.

1.12 Employers

1.12.1 Negotiate a smokefree workplace policy with employees or their 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.

  • Direct people who wish to stop smoking to local stop smoking support.

  • Implement NICE's guideline on smoking: workplace interventions. [2008, amended 2018]

For recommendations for employees of secondary care providers see NICE's guideline on smoking: acute, maternity and mental health services.

Terms used in this guideline

Behavioural support

Individual behavioural support involves scheduled face-to-face meetings between someone who smokes and a counsellor trained in smoking cessation. Typically, it involves weekly sessions over a period of at least 4 weeks after the quit date and is normally combined with pharmacotherapy.

Group behavioural support involves scheduled meetings in which people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy). This therapy is offered weekly for at least the first 4 weeks of a quit attempt (that is, for 4 weeks after the quit date). It is normally combined with pharmacotherapy.

Nicotine-containing products

Products that contain nicotine but do not contain tobacco and so deliver nicotine without the harmful toxins found in tobacco. Some have been licensed for smoking cessation by the Medicines and Healthcare products Regulatory Agency (MHRA; see nicotine replacement therapy below). Currently there are no licensed nicotine-containing e‑cigarettes on the market. E‑cigarettes on general sale are regulated under the Tobacco and Related Product Regulations by the MHRA. For further details see the MHRA website.

Nicotine-containing products on general sale

This includes over the counter NRT and nicotine-containing e‑cigarettes.

Nicotine replacement therapy

Nicotine replacement therapy (NRT) products are licensed for use as a smoking cessation aid and for harm reduction, as outlined in the British national formulary. They include transdermal patches, gum, inhalation cartridges, sublingual tablets and a nasal spray.

Text messaging

The text messages should be tailored to the person and aim to advise on quitting by giving information about the consequences of smoking and what to expect when trying to quit, encouraging and boosting self-efficacy, motivating and giving reminders of how to deal with difficult situations.

Stop smoking services

Services commissioned to deliver the interventions recommended in this guideline.

Stop smoking support

This includes interventions and support to stop smoking regardless of how services are commissioned or set up.

Very brief advice

Asking about current and past smoking behaviour, providing information on the consequences of smoking and stopping smoking, and advising on options for support and pharmacotherapy, in line with the NCSCT's training standard on very brief advice. This is consistent with the definition of brief intervention used in NICE's 2006 guideline (PH1).

For other public health and social care terms see the Think Local, Act Personal Care and Support Jargon Buster.



[1] See information on bupropion hydrochloride in the British national formulary.

[2] See information on varenicline in the British national formulary.

[3] The UK marketing authorisation for nicotine replacement therapy products varies for use in children and young people under 18. Refer to the summary of product characteristics for prescribing information on individual nicotine replacement therapy preparations.

[4] See reports by Public Health England (E-cigarettes and heated tobacco products: evidence review), the British Medical Association (E-cigarettes: balancing risks and opportunities) and the Royal College of Physicians (Nicotine without smoke: tobacco harm reduction).

  • Public Health England
  • National Institute for Health and Care Excellence (NICE)