1 Recommendations

The Programme Development Group (PDG) considers that the recommended approaches are cost effective.

The evidence underpinning the recommendations is listed in The evidence.

See also supporting evidence for the evidence reviews and economic modelling report.

For the research recommendations and gaps in research, see Recommendations for research and Gaps in the evidence respectively.

Whose health will benefit?

The recommendations aim to benefit people of all ages who smoke and who use, or work in, secondary care, including acute, maternity and mental health services.

Recommendation 1 Provide information for planned or anticipated use of secondary care

Who should take action?
  • Health and social care practitioners and managers in primary care, including GPs, health visitors and midwives.

  • Health and social care practitioners in acute, maternity and mental health services, including community services, drug and alcohol services, outpatient and pre-admission clinics.

  • Managers of secondary care admissions and pre-admission assessment services.

What action should they take?
  • Provide everyone with verbal and written information and advice about the smokefree policy before their appointment, procedure or hospital stay. This should convey:

    • the short- and long-term health benefits of stopping smoking at any time[1]

    • the risks of secondhand smoke

    • that all buildings and grounds are smokefree (see recommendation 11)

    • the types of support available to help them stop, or temporarily abstain from, smoking before, during and after an admission or appointment (see recommendations 3 and 4)

    • the different pharmacotherapies that can help with stopping smoking and temporary abstinence, where to obtain them (including from GPs) and how to use them.

  • Before a planned or likely admission, work with the person to include the management of smoking on admission or entry to the secondary care setting in their personal care plan.

  • Provide information for relatives, carers, friends and other visitors explaining why the hospital is smokefree and giving information about local stop smoking services.

Recommendation 2 Identify people who smoke and offer help to stop

Who should take action?
  • Health and social care practitioners in all acute, maternity and mental health services, including community services, drug and alcohol services, outpatient and pre-admission clinics.

  • Health and social care practitioners responsible for the care of people after compulsory admission to hospital under the Mental Health Act.

  • Stop smoking advisers and health and social care practitioners trained to provide intensive stop smoking support.

What action should they take?
  • During the first face-to-face contact, ask everyone if they smoke or have recently stopped smoking. Record smoking status and the date they stopped, if applicable, in the person's records (preferably computer-based) and any hand-held notes. If a person is unable to or does not want to talk about smoking, note this in their records and ask about their smoking status at the first available opportunity.

  • Advise everyone who smokes that secondary care settings are smokefree, and they must therefore abstain from smoking while admitted to or using secondary care services.

  • Encourage everyone who smokes to stop smoking completely. Explain that help is available, and if necessary provide immediate access to licensed nicotine-containing products or other pharmacotherapies, if appropriate (see recommendation 6).

  • Offer and, if the person agrees, arrange for them to receive intensive behavioural support, either during their current outpatient visit or during their inpatient stay (see recommendations 3 and 4).

  • For people using secondary care services in a community setting, staff who are trained to provide intensive behavioural support should offer and provide support (in line with recommendations 3 and 4). Other staff should offer and, if accepted, arrange a referral to a local stop smoking service.

  • Midwives should follow recommendation 1 in NICE guidance on quitting smoking in pregnancy and following childbirth (NICE public health guidance 26). This recommends that, in addition to the actions covered here, midwives should[2]:

    • assess the woman's exposure to tobacco smoke through discussion and use of a carbon monoxide (CO) assessment

    • refer all women who smoke (including those who smoke lightly or infrequently), have stopped in the last 2 weeks or have a CO reading indicative of smoking[3], to stop smoking services.

  • Midwives should help women who do not smoke but register CO levels of 3 parts per million (ppm) or more to identify the source of CO and take further action as
    appropriate[4].

  • If a person declines help to stop smoking, leave the offer open. At subsequent contacts, offer the support again.

  • Ensure all actions, discussions and decisions related to stop smoking advice, referrals or interventions are recorded in the person's records (preferably computer-based).

Recommendation 3 Provide intensive support for people using acute and mental health services

Who should take action?
  • Doctors, and stop smoking advisers, health and social care practitioners trained to provide intensive stop smoking support.

What action should they take?
  • Discuss current and past smoking behaviour and develop a personal stop smoking plan as part of a review of their health and wellbeing.

  • Provide information about the different types of stop smoking pharmacotherapies and how to use them.

  • Provide information about the types of intensive behavioural support available.

  • Offer and arrange or supply prescriptions of stop smoking pharmacotherapies (see recommendation 6).

  • For anyone who does not want, is not ready or is unable to stop completely, encourage the use of licensed nicotine-containing products to help them abstain and provide intensive behavioural support to maintain abstinence from smoking while in secondary care. Follow recommendation 8 in NICE guidance on tobacco: harm-reduction approaches to smoking (NICE public health guidance 45) where appropriate.

  • Offer, and if they agree, use measurements of exhaled carbon monoxide during each contact, to motivate and provide feedback on progress.

  • Alert the person's healthcare providers and prescribers to changes in smoking behaviour because other drug doses may need adjusting (see recommendation 7).

  • In addition, for people admitted to a secondary care setting:

    • Provide immediate support if necessary, and otherwise within 24 hours of admission.

    • Provide support (delivered in the setting) as often and for as long as needed during admission.

    • Offer weekly sessions, preferably face-to-face, for a minimum of 4 weeks after discharge. If it is not possible to provide this support after discharge, arrange a referral to a local stop smoking service.

  • In addition, for people receiving secondary care services in the community or at outpatient clinics (including pre-operative assessments):

    • Provide immediate support in the outpatient setting.

    • Offer weekly sessions, preferably face-to-face, for a minimum of 4 weeks after the date they stopped smoking. Arrange a referral to a local stop smoking service, if preferred by the person.

Recommendation 4 Provide intensive support for people using maternity services

Who should take action?
  • Stop smoking advisers and health and social care practitioners trained to provide intensive stop smoking support.

What action should they take?

Recommendation 5 Provide information and advice for carers, family, other household members and hospital visitors

Whose health will benefit?
  • People who smoke and live in the same household as someone who is using acute, maternity or mental health services. This includes partners, parents, other family members and carers.

  • People who use or visit acute, maternity and mental health settings.

Who should take action?
  • Health and social care practitioners in acute, maternity and mental health services.

  • Stop smoking advisers.

What action should they take?
  • During contact with partners, parents, other household members and carers of people using acute, maternity and mental health services:

    • provide clear information and advice about the risks of smoking and secondhand smoke

    • advise them not to smoke near the patient, pregnant woman, mother or child; this includes not smoking in the house or private vehicle

    • offer people who want to stop or reduce smoking a referral to a hospital or local stop smoking service, as appropriate.

  • During contact with partners of pregnant and breastfeeding women, follow recommendation 7 in NICE guidance on quitting smoking in pregnancy and following childbirth (NICE public health guidance 26).

  • Provide information and take the opportunity to explain to visitors that smoking is not allowed on the premises. Direct those who wish to use licensed nicotine-containing products for temporary abstinence to a point of sale in the hospital (see recommendation 8).

  • Provide information and take the opportunity to provide advice to visitors about the benefits of stopping smoking and how to contact local stop smoking services (for people who are working in the setting, see recommendation 13).

Recommendation 6 Advise on and provide stop smoking pharmacotherapies

Who should take action?
  • Stop smoking advisers and other healthcare practitioners who advise on, supply, or prescribe, pharmacotherapies.

What action should they take?
  • Advise people who smoke that licensed nicotine-containing products and other stop smoking pharmacotherapies help people to stop smoking and reduce cravings.

  • Emphasise that nicotine is not the major cause of damage to people's health from smoking tobacco, and that any risks from using licensed nicotine-containing products or other stop smoking pharmacotherapies are much lower than those of smoking.

  • Recommend and offer:

    • licensed nicotine-containing products (usually a combination of transdermal patches with a fast-acting product such as an inhalator, gum, lozenges or spray) to all people who smoke[5] or

    • varenicline[6] or bupropion as sole therapy as appropriate. Do not offer varenicline or bupropion to pregnant or breastfeeding women or people under the age of 18. Varenicline and bupropion can be used with caution in people with mental health problems[7].

  • Encourage people who do not want (or do not feel able) to stop smoking completely (including pregnant or breastfeeding women) to use licensed nicotine-containing products to help reduce cravings to smoke during their stay or visit.

  • If stop smoking pharmacotherapy is accepted, ensure that it is provided immediately.

  • The person should remove nicotine replacement therapy (NRT) patches 24 hours before microvascular reconstructive surgery and surgery using vasopressin injections.

  • When people are discharged from hospital ensure they have sufficient stop smoking pharmacotherapy to last at least 1 week or until their next contact with a stop smoking service.

  • Encourage people who are already using an unlicensed nicotine-containing product (such as unlicensed electronic cigarettes) to switch to a licensed product[8]. Advise the person of local policies on indoor and outdoor use of unlicensed nicotine-containing products.

  • See also NICE guidance on varenicline (NICE technology appraisal guidance 123) and smoking cessation services (NICE public health guidance 10).

Recommendation 7 Adjust drug dosages for people who have stopped smoking

Who should take action?
  • Doctors and other healthcare practitioners who advise on, or prescribe, pharmacotherapies.

  • Pharmacists.

  • Health and social care practitioners in acute, maternity and mental health services.

What action should they take?
  • Ensure people who use drugs that are affected by smoking (or stopping smoking) are monitored, and the dosage adjusted if appropriate. Drugs that are affected include clozapine, olanzapine, theophylline and warfarin. See relevant guidelines for further details, for example, UK Medicines Information.

  • Discuss with secondary care users and their carers the potential to reduce the dose of some drugs when stopping smoking. Advise them to seek medical advice if they notice any side effects of changing smoking behaviour.

Recommendation 8 Make stop smoking pharmacotherapies available in hospital

Who should take action?
  • Hospital pharmacists and managers.

What action should they take?
  • Ensure hospital pharmacies stock varenicline, bupropion and a range of licensed nicotine-containing products (including transdermal patches and a range of fast-acting products) for patients and staff (see recommendations 6 and 13).

  • Ensure people using secondary care have access to stop smoking pharmacotherapies at all times.

  • Ensure a range of licensed nicotine-containing products are available for sale in hospital to visitors and staff.

Recommendation 9 Put referral systems in place for people who smoke

Who should take action?
  • Managers in publicly-funded trusts, hospitals and clinics providing acute, maternity and mental health services.

  • Managers and providers of stop smoking services.

  • GPs and practice managers in primary care.

  • Commissioners.

What action should they take?
  • Ensure there are systems for consistently recording and maintaining records of people's smoking status. The records should:

    • provide a prompt for action (including the referral of people to stop smoking support)

    • ensure smoking status is consistent in all patient records

    • be stored for easy access and audit.

  • Make sure there is a robust system in place (preferably electronic) to ensure continuity of care between secondary care and local stop smoking services for people moving in and out of secondary care.

Recommendation 10 Provide leadership on stop smoking support

Who should take action?
  • Directors and senior managers in publicly-funded secondary care services.

What action should they take?
  • Assign a clinical or medical director to lead on stop smoking support for people who use, or work in, secondary care services. The designated lead should ensure:

    • an organisation-wide smokefree policy is in place (see recommendation 11)

    • the organisation has an annual improvement programme for stop smoking support given to people who use, or work in, secondary care services

    • stop smoking support (for patients and staff) is promoted and communicated effectively (see recommendation 12) to initiate a cultural change within the organisation

    • referral and support pathways are part of the organisation's service plan

    • hospitals have an on-site stop smoking service

    • staff in secondary care services deliver stop smoking support to help people stop, or temporarily abstain, from smoking, in line with the recommendations in this guidance

    • the quality of stop smoking services continues to improve

    • progress and outcomes in each clinical area are monitored, for example, recording of individual smoking status (including at the time of giving birth), the number of referrals, uptake of interventions, prescribing of stop smoking pharmacotherapies, 4-week quit rates, training of staff

    • performance monitoring and feedback on outcomes is provided to all staff.

Recommendation 11 Develop smokefree policies

Who should take action?
  • Directors and senior managers of publicy-funded secondary care services or their representatives (including occupational health services and estates management).

What action should they take?
  • Develop a policy for smokefree grounds in collaboration with staff and people who use secondary care services, or their representatives. The policy should:

    • set out a clear timeframe to establish or reinstate smokefree grounds

    • identify the roles and responsibilities of staff

    • prohibit staff-supervised and staff-facilitated smoking breaks in secondary care

    • identify adequate resources to support the policy

    • prohibit the sale of tobacco products in secondary care settings

    • be periodically reviewed and updated, in line with all other organisational policies.

  • Ensure smokefree implementation plans include the following:

    • stop smoking and temporary abstinence support for staff and people who use secondary care services (in line with the recommendations in this guidance)

    • training for staff (see recommendation 14)

    • removal of shelters or other designated outdoor smoking areas

    • staff, contractor and volunteer contracts that do not allow smoking during work hours or when recognisable as an employee (for example, when in uniform, or wearing identification, or handling hospital business)

    • how to work with service users and carers to protect staff from tobacco smoke when they are visiting the homes of people using secondary care services[9].

  • Ensure policies, procedures and resources are in place to:

    • facilitate compliance with, and resolve immediately, any breaches of smokefree policies, including a process for staff to report incidents

    • support staff to encourage compliance with the smokefree policy

    • work with services users, carers, staff and visitors to overcome any problems that may result from smoking restrictions (supported by 'personal care plans' as covered in recommendation 1).

  • Ensure all staff are aware of the smokefree policy and comply with it.

Recommendation 12 Communicate the smokefree policy

Who should take action?
  • Directors and senior managers of publicly-funded secondary care services or their representatives (including the communications team, occupational health services and estates management).

What action should they take?
  • Develop, deliver and maintain a communications strategy[10] about local smokefree policy requirements. This should include information for people who use secondary care services and their parents or carers, staff and visitors, and the wider local population. The strategy should include:

    • clear, consistent messages about the need to keep buildings and grounds smokefree

    • positive messages about the health benefits of a smokefree environment

    • acknowledgement of the duty of the health and social care profession to provide a safe and healthy environment for staff and people who use or visit secondary care services

    • information about stop smoking support and how to access services, including support for temporary abstinence, for staff and people who use secondary care services

    • information emphasising that staff should not smoke at any time during working hours or when recognisable as an employee, contractor or volunteer (for example, when in uniform, wearing identification, or handling hospital business).

Recommendation 13 Support staff to stop smoking

Whose health will benefit?
  • People who work in secondary care settings, in particular, those who have direct contact with people using the services. (This includes support staff, volunteers, those working for agencies or as locums and people employed by contractors.)

Who should take action?
  • Directors, managers and staff in secondary care services.

  • Providers of occupational health and hospital stop smoking services.

What action should they take?
  • Take action in line with NICE guidance on workplace interventions to promote smoking cessation (NICE public health guidance 5):

    • advise all staff who smoke to stop

    • offer staff in-house stop smoking support

    • provide contact details for community support if preferred

    • allow staff to attend stop smoking services during working hours without loss of pay.

  • Advise staff who do not want, or are not ready or able to stop completely, to use licensed nicotine-containing products to help them abstain during working hours. Advise them where to obtain them (including from GPs).

  • Offer and provide intensive behavioural support to maintain abstinence from smoking during working hours. Follow recommendation 8 in NICE guidance on Tobacco: harm-reduction approaches to smoking (NICE public health guidance 45) where appropriate.

Recommendation 14 Provide stop smoking training for frontline staff

Who should take action?
  • Organisations providing training in smoking cessation and temporary abstinence such as the National Centre for Smoking Cessation and Training (NCSCT).

  • Royal colleges, medical, midwifery and nursing schools, undergraduate and postgraduate training providers.

  • Healthcare professional training schools.

  • Local education and training boards.

  • Public health commissioners, health and wellbeing boards, clinical commissioning groups.

  • Directors, managers and healthcare professionals in medical, surgical and maternity hospitals and clinics.

  • Directors and managers in mental health services, including drug and alcohol treatment services.

  • Managers of stop smoking services.

  • Health Education England.

What action should they take?
  • Ensure relevant curricula for frontline staff include the range of interventions and practice to help people stop smoking, as outlined in this guidance.

  • Ensure all frontline staff are trained to deliver advice around stopping smoking and referral to intensive support, in line with recommendations 1 and 2. They should know what local and hospital-based stop smoking services offer and how to refer people to them.

  • Ensure online training can be completed and updated annually as part of NHS mandatory training (for example, training provided by the NCSCT).

  • Ensure all frontline staff are trained to talk to people in a sensitive manner about the risks of smoking and benefits of stopping.

  • Ensure all staff who deliver intensive stop smoking support are trained to the minimum standard described by the NCSCT (or its equivalent), with additional training that is relevant to their clinical specialism.

  • Ensure all staff are provided with information about smokefree policies and instructions about their roles and responsibilities in maintaining a smokefree work environment. They should be advised on what action to take in the event of negative responses to smoking restrictions.

Recommendation 15 Ensure local tobacco control strategies include secondary care

Who should take action?
  • Directors and senior managers in publicly-funded secondary care services.

  • Directors of public health.

  • Public health commissioners, clinical commissioning groups.

  • Local government, health and wellbeing boards and tobacco control alliances.

What action should they take?
  • Ensure the joint strategic needs assessment considers the impact of smoking on local communities. Ensure it also identifies expected numbers of particular groups of people who are at very high risk (for example, people with different mental health problems), the proportion reached by services and the numbers who successfully stop smoking.

  • Make it explicit in the local tobacco control strategy that people working in secondary care should:

    • communicate key messages about tobacco-related harm to everyone who uses services

    • develop policies and support to help people stop smoking

    • identify people who wish to stop smoking and, if appropriate, refer them on to a stop smoking adviser

    • implement a comprehensive smokefree policy that includes the grounds.

  • Develop a local stop smoking care pathway and referral procedure to ensure there is continuity of care between primary, community and secondary care.

Recommendation 16 Commission smokefree secondary care services

Who should take action?
  • Commissioners of health services.

What action should they take?
  • Ensure all secondary care buildings and grounds are smokefree.

  • Ensure the NHS standard contract and local authority contract includes smokefree strategies.

  • Ensure services are commissioned to provide a range of stop smoking pharmacotherapies.

  • Ensure health and social care practitioners in secondary care identify people who smoke and offer them advice, support and treatment, or offer them a referral to a stop smoking service.

  • Ensure all hospitals have an on-site stop smoking service.

  • Ensure there is a requirement within service specifications and service level agreements that all staff are trained to deliver advice on stopping smoking and to make a referral to intensive support. It should also require that relevant staff undertake regular continuing professional development in how to provide intensive stop smoking support.

  • Monitor and audit the implementation and impact of the recommendations in this guidance. This may include recording of individual smoking status (including at the time of giving birth), the number of referrals, uptake of interventions, prescribing of stop smoking pharmacotherapies, 4-week quit rates, training of staff. Ensure the needs of higher risk groups identified in the joint strategic needs assessment are being met (see recommendation 15).

  • Ensure there are resources to enable secondary care providers to maintain smokefree policies.

  • Ensure care pathways include: identification of people who smoke, provision of advice on likely smoking-related complications, advice to stop smoking and proactive referral to stop smoking services.

  • Ensure stop smoking pharmacotherapies are included in secondary care formularies.

  • Include sale of licensed nicotine-containing products in secondary care settings (for example, in hospital shops) within formulary and guidelines policy.



[1] Stopping smoking any time before surgery has no detrimental effects for surgery patients. There are significant positive effects of stopping smoking in the 8 weeks running up to surgery.

[2] This is an edited extract – please see the full recommendation for details.

[3] Quitting smoking in pregnancy and following childbirth (NICE public health guidance 26) states that it is unclear what constitutes the best cut-off point for determining smoking status; some organisations suggest a CO level as low as 3 parts per million (ppm), others suggest a cut-off point of 6–10 ppm. While NICE public health guidance 26 recommends 7 ppm, it states that when trying to identify pregnant women who smoke, it is best to use a low cut-off point to avoid missing someone who may need help to quit.

[4] Other sources include, for example, household or other secondhand smoke, heating appliances or traffic emissions.

[5] Ideally, pregnant or breastfeeding women should stop smoking without using licensed nicotine-containing products, but if this is not possible, these products may be used. For further information, see the summary of product characteristics (SPCs) for the individual drugs on the Electronic Medicines Compendium (EMC) website.

[6] See NICE guidance on varenicline (NICE technology appraisal guidance 123).

[7] See the summary of product characteristics (SPCs) for varenicline and bupropion on the Electronic Medicines Compendium (EMC) website for further information.

[8] At the time of publication (November 2013), nicotine replacement therapy products were the only licensed nicotine-containing products. However, the Medicines and Healthcare products Regulatory Agency (MHRA) has decided that all nicotine-containing products should be regulated once the European Commission's revised Tobacco Products Directive comes into effect in the UK (this is expected to be in 2016). In the meantime, the UK government will encourage applications for medicines licences for nicotine-containing products and will make best use of the flexibilities within the existing framework to enable licensed products to be available. This means that there may be both licensed and unlicensed products available until that date. For further details, see the MHRA website.

[9] In accordance with smokefree legislation, employers should take action to reduce the risk to the health and safety of their employees from secondhand smoke to as low a level as is reasonably practicable.

[10] Communications could include newsletters, pamphlets, posters and signage. Smokefree signs for vehicles or areas that are enclosed or substantially enclosed must comply with regulations under the Health and Safety at Work etc Act 1974.

  • National Institute for Health and Care Excellence (NICE)