1 Recommendations

This document constitutes the Institute's formal guidance on brief interventions and referrals for smoking cessation in primary care and other settings.

The Public Health Interventions Advisory Committee (PHIAC) considered the evidence of effectiveness and cost effectiveness and comments from stakeholders. The original referral from the Department of Health made particular reference to pregnant women and vulnerable groups. However, PHIAC considered that the evidence was insufficient to make specific recommendations for these groups. The resulting recommendations apply to all smokers.

The recommendations in this section are presented without any reference to evidence statements. Appendix A repeats all the recommendations and lists their linked evidence statements.

PHIAC (see appendix C) considered the evidence of effectiveness and cost effectiveness, and comments from stakeholders and service users.

The methods used to develop the guidance are summarised in appendix D. Details of supporting documents are given in appendix E.

1.1 Brief interventions in health and community care

Brief interventions involve opportunistic advice, discussion, negotiation or encouragement. They are commonly used in many areas of health promotion and are delivered by a range of primary and community care professionals.

For smoking cessation, brief interventions typically take between 5 and 10 minutes and may include one or more of the following:

  • simple opportunistic advice to stop

  • an assessment of the patient's commitment to quit

  • an offer of pharmacotherapy and/or behavioural support

  • provision of self-help material and referral to more intensive support such as the NHS Stop Smoking Services.

The particular package that is provided will depend on a number of factors, including the individual's willingness to quit, how acceptable they find the intervention on offer and the previous ways they have tried to quit. A diagram summarising this care pathway is available online.

1.1.1 Practice recommendations

Who should receive advice?

Recommendation 1

Everyone who smokes should be advised to quit, unless there are exceptional circumstances[3]. People who are not ready to quit should be asked to consider the possibility and encouraged to seek help in the future. If an individual who smokes presents with a smoking-related disease, the cessation advice may be linked to their medical condition.

Recommendation 2

People who smoke should be asked how interested they are in quitting[3]. Advice to stop smoking should be sensitive to the individual's preferences, needs and circumstances: there is no evidence that the 'stages of change' model[4] is more effective than any other approach.

Who should advise smokers and how?

Recommendation 3

GPs should take the opportunity to advise all patients[3] who smoke to quit when they attend a consultation. Those who want to stop should be offered a referral to an intensive support service (for example, NHS Stop Smoking Services). If they are unwilling or unable to accept this referral they should be offered pharmacotherapy in line with NICE technology appraisal guidance no. 39[5] and additional support. The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year, where possible.

Recommendation 4

Nurses in primary and community care should advise everyone who smokes[3] to stop and refer them to an intensive support service (for example, NHS Stop Smoking Services). If they are unwilling or unable to accept this referral they should be offered pharmacotherapy by practitioners with suitable training, in line with NICE technology appraisal guidance no. 39[5], and additional support. Nurses who are trained NHS stop smoking counsellors may 'refer' to themselves where appropriate. The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year, where possible.

Recommendation 5

All other health professionals, such as hospital clinicians, pharmacists and dentists, should refer people who smoke[3] to an intensive support service (for example, NHS Stop Smoking Services). If the individual is unwilling or unable to accept this referral, practitioners with suitable training should offer a prescription of pharmacotherapy in line with NICE technology appraisal guidance no. 39[5], and additional support. Those who are trained NHS stop smoking counsellors may 'refer' to themselves. Where possible, the smoking status of those who are not ready to stop should be recorded in clinical records and reviewed with the individual once a year, where possible.

Recommendation 6

Community workers[6] should refer people who smoke[3] to an intensive support service (for example, NHS Stop Smoking Services). Those who are trained NHS stop smoking counsellors may 'refer' to themselves.

1.1.2 Strategic recommendations for policy makers, commissioners and managers

Recommendation 7

Strategic health authorities, NHS hospital trusts, primary care trusts (PCTs), community pharmacies, local authorities and local community groups should review smoking cessation policies and practices to take account of the recommendations in this guidance.

Recommendation 8

Smoking cessation advice and support should be available in community, primary and secondary care settings for everyone who smokes. Local policy makers and commissioners should target hard to reach and deprived communities including minority ethnic groups, paying particular attention to their needs.

Recommendation 9

Monitoring systems should be set up to ensure health professionals have access to information on the current smoking status of their patients. This should include information on: a) the most recent occasion on which advice to stop was given, b) the nature of advice offered and c) the response to that advice.



[3] Occasionally it might be inappropriate to advise a patient to quit: for example, because of their presenting condition or personal circumstances.

[4] DiClemente CC, Prochaska J. et al. (1991) The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology. Vol 59(2) 295-304.

[5] Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation. NICE technology appraisal no. 39 (2002). [Replaced by NICE public health guidance 10]

[6] Community workers are practitioners working outside the health sector who have a remit for smoking cessation.