4 Recommendations

This document is the Institute's formal guidance on smoking cessation services. When writing the recommendations, the PDG (see appendix A) considered the evidence of effectiveness (including cost effectiveness), fieldwork data and comments from stakeholders. Full details are available on the Institute's website.

The evidence statements that underpin the recommendations are listed in appendix C.

The evidence reviews, supporting evidence statements and economic appraisal are available on the Institute's website.

The PDG considers all of the recommended interventions to be cost effective.

The PDG also considered whether a recommendation should only be implemented as part of a research programme, where evidence was lacking. For the research recommendations and other gaps in the research, see section 6 and appendix D respectively.

Effective interventions

The following smoking cessation interventions have been proven to be effective.

Brief interventions

Brief interventions for smoking cessation involve opportunistic advice, discussion, negotiation or encouragement and referral to more intensive treatment, where appropriate. They are delivered by a range of primary and community care professionals, typically in less than 10 minutes. The package provided depends on a number of factors including the individual's willingness to quit, how acceptable they find the intervention and previous methods they have used. It may include one or more of the following:

  • simple opportunistic advice

  • an assessment of the individual's commitment to quit

  • pharmacotherapy and/or behavioural support

  • self-help material

  • referral to more intensive support such as the NHS Stop Smoking Service.

(NICE 2006a and NICE 2006b)

Individual behavioural counselling

Individual behavioural counselling 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. (Lancaster and Stead 2005a; NICE 2006b; NICE 2006c)

Group behaviour therapy

Group behaviour therapy involves scheduled meetings where 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 following the quit date). It is normally combined with pharmacotherapy.
(NICE 2006b; NICE 2006c; Stead and Lancaster 2005)

Pharmacotherapies

Smoking cessation advisers and healthcare professionals may recommend and prescribe nicotine replacement therapy (NRT), varenicline or bupropion as an aid to help people to quit smoking, along with giving advice, encouragement and support, or referral to a smoking cessation service. Before prescribing a treatment, they take into account the person's intention and motivation to quit and how likely it is they will follow the course of treatment. They should also consider which treatments the individual prefers, whether they have attempted to stop before (and how), and if there are medical reasons why they should not be prescribed particular pharmacotherapies. (NICE 2002; NICE 2006b; NICE 2007)

Self-help materials

Self-help materials comprise any manual or structured programme, in written or electronic format, that can be used by individuals in a quit attempt without the help of health professionals, counsellors or group support. Materials can be aimed at anyone who smokes, particular populations (for example, determined by age or ethnic group) or may be interactively tailored to individual need. (Lancaster and Stead 2005b; NICE 2006b)

Telephone counselling and quitlines

Telephone counselling and quitlines provide encouragement and support over the telephone to anyone who smokes who wants to quit, or who has recently quit. Counsellors can call the client (a proactive service) or the client can call the service (a reactive service). (Stead et al 2006;NICE 2006b; NICE 2006c)

Mass media

Mass-media campaigns combine multiple types of media, such as TV, radio and national newspaper advertising. They can be used alone to encourage and support quit attempts or combined with other activities at local, regional and national levels.
(Gutierrez 2007)

Different levels of service

Department of Health guidance on how to develop effective stop smoking services covers three levels: brief interventions, intensive one-to-one support and advice, and group interventions. These are frequently referred to as level one, level two and level three services, respectively. For a full explanation of each level of advice, see the 'Standard for training in smoking cessation treatments').

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 this section).

  • 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)

Recommendation 3

Who is the target population?

People who want to stop smoking.

Who should take action?

Commissioners and managers of telephone quitline services.

What action should they take?
  • Ensure publicly sponsored telephone quitlines offer a rapid, positive and authoritative response. Where possible, callers whose first language is not English should have access to information and support in their chosen language.

  • All staff should receive smoking cessation training (at least in brief interventions to help people stop smoking).

  • Staff who offer counselling should be trained to at least level two (individual behavioural counselling) and preferably, they should hold an appropriate counselling qualification. Training should comply with the 'Standard for training in smoking cessation treatments' or its updates.

Pharmocotherapies and other treatments

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)

Recommendation 5

This recommendation has been replaced by Tobacco: harm reduction approaches to smoking (NICE public health guidance 45).

Specific groups

Recommendation 6

Who is the target population?

People receiving care and advice from a health professional in primary care or secondary care.

Who should take action?
  • PCTs.

  • Healthcare professionals.

What action should they take?
Primary care providers
  • Healthcare professionals should be trained to give brief advice on stopping tobacco use and should have contact with the local NHS Stop Smoking Service to which they can refer people.

  • Healthcare professionals should identify and record the smoking and/or tobacco use status of all their patients. Those who use tobacco should be:

  • reminded at every suitable opportunity of the health benefits of stopping

  • offered brief advice and, if they want to stop using tobacco, referred to the local NHS Stop Smoking Service. If patients do not wish to attend the service, they should be offered brief advice and support to help them quit, and pharmacotherapy as appropriate.

  • Patients referred for elective surgery should be encouraged to stop smoking before the operation. Patients who want to stop smoking for good should also be referred to the local NHS Stop Smoking Service.

  • See also recommendations 1, 7 and 9 from Smoking cessation in secondary care: acute, maternity and mental health services (NICE public health guidance 48).

Recommendation 7

Who is the target population?

People with cardiovascular or respiratory disease who smoke.

Who should take action?
  • Healthcare professionals or counsellors who advise on, prescribe or dispense pharmacotherapies for stopping smoking.

  • Cardiac rehabilitation teams.

What action should they take?
Primary care providers
  • Offer brief advice or, preferably, behavioural support from the local NHS Stop Smoking Service and prescriptions of NRT, varenicline or bupropion, according to clinical judgement.

  • This supersedes NICE technology appraisal guidance 39 on NRT and bupropion. (See also NICE technology appraisal guidance 123 on varenicline and NICE clinical guideline 12 on chronic obstructive pulmonary disease [replaced by NICE clinical guideline 101).

  • See also recommendations 1, 7 and 9 from Smoking cessation in secondary care: acute, maternity and mental health services (NICE public health guidance 48).

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)

Recommendation 9

Who is the target population?

Mothers of infants and young children, particularly breastfeeding mothers who smoke, and partners and family members who smoke.

Who should take action?

GPs, midwives, health visitors, community pharmacists and smoking cessation counsellors who advise on, or prescribe, NRT.

What action should they take?
  • At the first contact, discuss the smoking status of the woman and her partner, provide information about the risks of secondhand smoke to young children and address any concerns about stopping smoking.

  • Offer information, advice and support on how to quit smoking and encourage use of local NHS Stop Smoking Services by providing details on when, where and how to access them.

  • Use any opportunity to offer those mothers who are (or who may be) eligible for the Healthy Start scheme practical and personalised information, advice and support to help them stop smoking.

  • Discuss the risks and benefits of NRT with breastfeeding mothers who have tried but have been unable to stop smoking unaided. Use professional judgement to decide whether or not to advise use of NRT or to offer an NRT prescription.

  • Advise breastfeeding 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)

Recommendation 10

Who is the target population?

Young people aged 12–17 who show a strong commitment to quit smoking.

Who should take action?

Healthcare professionals or counsellors who advise on, or prescribe, NRT.

What action should they take?
  • Offer young people aged 12–17 information, advice and support on how to stop smoking. Encourage use of local NHS Stop Smoking Services by providing details on when, where and how to access them.

  • Use professional judgement to decide whether or not to offer NRT to young people over 12 years who show clear evidence of nicotine dependence. If NRT is prescribed, offer it as part of a supervised regime.

This supersedes NICE technology appraisal guidance 39 on NRT and bupropion. (See also NICE public health guidance 1 on smoking cessation and NICE technology appraisal guidance 123 on varenicline)

Education and training

Recommendation 11

Who is the target population?

NHS Stop Smoking Services advisers and coordinators.

Who should take action?

Commissioners and managers of NHS Stop Smoking Services.

What action should they take?

Recommendation 12

Who is the target population?

Doctors, nurses, midwives, pharmacists, dentists, telephone quitline counsellors and others who advise people on how to quit smoking.

Who should take action?

Those responsible for the education and training of healthcare workers and others who advise people how to quit smoking.

What action should they take?
Primary care providers
  • Train all frontline healthcare staff to offer brief advice on smoking cessation in accordance with NICE guidance ('Brief interventions and referral for smoking cessation in primary care and other settings'). Also train them to make referrals, where necessary and possible, to NHS Stop Smoking Services and other publicly funded smoking cessation services.

  • Ensure training on how to support people to quit smoking is part of the core curriculum for healthcare undergraduates and postgraduates.

  • Train all NHS Stop Smoking Services practitioners using a programme that complies with the 'Standard for training in smoking cessation treatments' or its updates.

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

  • Encourage and train healthcare professionals to ask patients or clients about all forms of tobacco use and to advise them of the dangers of exposure to secondhand smoke.

Strategies, policies and plans

Recommendation 13

Who is the target population?

Everyone who smokes or uses tobacco in any other form.

Who should take action?

PCTs, SHAs, local authorities, local strategic partnerships.

What action should they take?
  • Set local targets for reducing tobacco use based on the characteristics of the local population and the prevalence of smoking and other forms of tobacco consumption, such as oral tobacco. Embed these targets in any partnership arrangements between local authorities and PCTs (for example, local area agreements).

  • Develop a policy to ensure that effective smoking cessation services are provided as part of the local tobacco control strategy.

For recommendations on the use of smokeless tobacco see Smokeless tobacco cessation - South Asian communities (NICE public health guidance 39).

Recommendation 14

Who is the target population?

Everyone who smokes or uses tobacco in any other form.

Who should take action?

Organisers and planners of local, regional and national public education and communications campaigns.

What action should they take?
  • Coordinate communications strategies to support the delivery of smoking cessation services, telephone quitlines, school-based interventions, forthcoming tobacco control policy changes and any other activities designed to help people to stop using tobacco.

  • 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 reviews by the Cochrane Collaboration and the Global Dialogue for Effective Stop Smoking Campaigns.

    • 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 can work well

    • 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 minority ethnic groups to address inequalities.

For recommendations on the use of smokeless tobacco see Smokeless tobacco cessation - South Asian communities (NICE public health guidance 39).

For recommendations for secondary care providers see Smoking cessation in secondary care: acute, maternity and mental health services (NICE public health guidance 48).

Recommendation 15

Who is the target population?

People who live or work in prisons, military establishments and care institutions, and who smoke or use tobacco in other forms.

Who should take action?

Managers of prisons, military establishments and long-stay health centres, such as mental healthcare units.

What action should they take?

Develop a policy, using guidance provided by the Department of Health, to ensure that effective smoking cessation services are provided and promoted.

(See also NICE public health guidance 1 on smoking cessation and NICE public health guidance 5 on workplace smoking cessation)

For recommendations for secondary care providers see Smoking cessation in secondary care: acute, maternity and mental health services (NICE public health guidance 48).

For recommendations for people who stay or work in closed institutions see Tobacco: harm-reduction approaches to smoking (NICE public health guidance 45).

Recommendation 16

Who is the target population?

Employees whose workplace is subject to regulations under the 2006 Health Act.

Who should take action?

Employers.

What action should they take?

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 services that offer appropriate support, for example, the NHS Stop Smoking Services

  • implement the NICE public health guidance, 'Workplace interventions to promote smoking cessation'.

For recommendations for secondary care providers see Smoking cessation in secondary care: acute, maternity and mental health services (NICE public health guidance 48).