1 Key priorities

This section lists the four recommendations that have been identified as key priorities for implementation, on the basis of the following criteria:

  • impact on health inequalities

  • impact on health of the target population

  • cost effectiveness

  • balance of risks and benefits.

  • ease of implementation

  • speed of impact

Smoking cessation services

Recommendation 1

Who is the target population?

Everyone who smokes or uses any other form of tobacco.

Who should take action?
  • Primary care trusts (PCTs), strategic health authorities (SHAs).

  • Commissioners of publicly funded smoking cessation services.

What action should they take?
  • Determine the characteristics of the local population of people who smoke or use other forms of tobacco. Determine the prevalence of all forms of tobacco use locally.

  • Ensure NHS Stop Smoking Services target minority ethnic and socioeconomically disadvantaged communities in the local population.

  • Ensure NHS Stop Smoking Services provide a good service by maintaining adequate staffing levels, including a full-time coordinator (or the equivalent).

  • Set realistic performance targets for both the number of people using the service and the proportion who successfully quit smoking. These targets should reflect the demographics of the local population. Services should:

    • aim to treat at least 5% of the estimated local population of people who smoke or use tobacco in any form each year

    • aim for a success rate of at least 35% at 4 weeks, validated by carbon monoxide monitoring. This figure should be based on all those who start treatment, with success defined as not having smoked in the third and fourth week after the quit date. Success should be validated by a CO monitor reading of less than 10 ppm at the 4-week point. This does not imply that treatment should stop at 4 weeks.

  • Audit performance data routinely and independently and make the results publicly available. Audits should also be carried out on exceptional results – 4-week quit rates lower than 35% or above 70% – to determine the reasons for unusual performance, and to help identify best practice and ensure it is being followed.

  • Establish links between contraceptive services, fertility clinics and
    ante- and postnatal services. These links should ensure health professionals use the many opportunities available to them (at various stages of the woman's life) to offer smoking advice or referral to a specialist service, where appropriate.

(See also NICE public health guidance 1 on smoking cessation in primary care and other settings)

Recommendation 2

Who is the target population?

Everyone who smokes or uses tobacco in any other form.

Who should take action?

Managers and providers of NHS Stop Smoking Services.

What action should they take?
  • Offer behavioural counselling, group therapy, pharmacotherapy or a combination of treatments that have been proven to be effective (see the list at the start of section 4).

  • Ensure clients receive behavioural support from a person who has had training and supervision that complies with the 'Standard for training in smoking cessation treatments' or its updates.

  • Provide tailored advice, counselling and support, particularly to clients from minority ethnic and disadvantaged groups. Provide services in the language chosen by clients, wherever possible.

  • Ensure the local NHS Stop Smoking Service aims to treat minority ethnic and disadvantaged groups at least in proportion to their representation in the local population of tobacco users.

(See also NICE public health guidance 1 on smoking cessation)

Pharmocotherapies

Recommendation 4

Who is the target population?

People who want to stop smoking.

Who should take action?

Healthcare professionals who advise on, or prescribe, nicotine replacement therapy (NRT), varenicline or bupropion.

What action should they take?
  • Offer NRT, varenicline or bupropion, as appropriate, to people who are planning to stop smoking.

  • Offer advice, encouragement and support, including referral to the NHS Stop Smoking Service, to help people in their attempt to quit.

  • NRT, varenicline or bupropion should normally be prescribed as part of an abstinent-contingent treatment, in which the smoker makes a commitment to stop smoking on or before a particular date (target stop date). The prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date. Normally, this will be after 2 weeks of NRT therapy, and 3–4 weeks for varenicline or bupropion, to allow for the different methods of administration and mode of action. Subsequent prescriptions should be given only to people who have demonstrated, on re-assessment, that their quit attempt is continuing.

  • Explain the risks and benefits of using NRT to young people aged from 12 to 17, pregnant or breastfeeding women, and people who have unstable cardiovascular disorders. To maximise the benefits of NRT, people in these groups should also be strongly encouraged to use behavioural support in their quit attempt.

  • Neither varenicline or bupropion should be offered to young people under 18 nor to pregnant or breastfeeding women.

  • Varenicline or bupropion may be offered to people with unstable cardiovascular disorders, subject to clinical judgement.

  • If a smoker's attempt to quit is unsuccessful using NRT, varenicline or bupropion, do not offer a repeat prescription within 6 months unless special circumstances have hampered the person's initial attempt to stop smoking, when it may be reasonable to try again sooner.

  • Do not offer NRT, varenicline or bupropion in any combination.

  • Consider offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past.

  • Do not favour one medication over another. The clinician and patient should choose the one that seems most likely to succeed.

  • When deciding which therapies to use and in which order, discuss the options with the client and take into account:

    • whether a first offer of referral to the NHS Stop Smoking Service has been made

    • contra-indications and the potential for adverse effects

    • the client's personal preferences

    • the availability of appropriate counselling or support

    • the likelihood that the client will follow the course of treatment

    • their previous experience of smoking cessation aids.

This supersedes NICE technology appraisal guidance 39 on NRT and bupropion. (See also NICE technology appraisal guidance 123 on varenicline)

Pregnancy

Recommendation 8

Who is the target population?

Women who smoke and who are either pregnant or are planning a pregnancy, and their partners and family members who smoke.

Who should take action?

All those responsible for providing health and support services for pregnant women, for those wishing to become pregnant, and for their partners. This includes: those working in fertility clinics, midwives, GPs, dentists, hospital and community pharmacists, and those working in children's centres, voluntary organisations and occupational health services.

What action should they take?
  • At the first contact with the woman, discuss her smoking status, provide information about the risks of smoking to the unborn child and the hazards of exposure to secondhand smoke. Address any concerns she and her partner or family may have about stopping smoking.

  • Offer personalised information, advice and support on how to stop smoking. Encourage pregnant women to use local NHS Stop Smoking Services and the NHS Pregnancy Smoking Helpline by providing details on when, where and how to access them. Consider visiting pregnant women at home if it is difficult for them to attend specialist services.

  • Monitor smoking status and offer smoking cessation advice, encouragement and support throughout the pregnancy and beyond.

  • Discuss the risks and benefits of NRT with pregnant women who smoke, particularly those who do not wish to accept the offer of help from the NHS Stop Smoking Service. If a woman expresses a clear wish to receive NRT, use professional judgement when deciding whether to offer a prescription.

  • Advise pregnant women using nicotine patches to remove them before going to bed.

This supersedes NICE technology appraisal guidance 39 on NRT and bupropion. (See also NICE public health guidance 1 on smoking cessation)