3 Considerations

The Programme Development Group (PDG) took account of a number of factors and issues when developing the recommendations, as follows. Please note: this section does not contain recommendations. (See Recommendations.)


3.1 Smoking rates and related morbidity and mortality are much higher in certain groups, particularly the most vulnerable in society. These differences in smoking rates are a major contributor to inequalities in health status and outcomes. Smoking also exacerbates poverty. Reducing smoking among people who use secondary care services can help reduce these effects.

3.2 There is relatively limited evidence on the effectiveness of stop smoking and temporary abstinence interventions for people who use mental health services. Much of what is available originated from the USA. The PDG noted, however, the importance of offering the same level of support to people who use mental health services to prevent a further widening of the already substantial health gap. It also noted that there may be a need for more intensive or tailored support to meet the needs of highly addicted smokers facing challenging life circumstances (see Recommendations for research).

3.3 There is evidence from the USA to show financial incentives are an effective way to encourage pregnant women to quit. However, there is limited evidence on the type of rewards that would be effective or acceptable in the UK.

3.4 Smokers who undergo surgery are more likely to have longer hospital stays and are more likely to need intensive care compared with people who don't smoke. Smokers also have an increased risk of emergency readmission. Stopping smoking as soon as possible before surgery can reduce these risks. The PDG noted the results of a recent systematic review and meta-analyses of studies that validated smoking status (Myers et al. 2011). This showed that there is no detrimental effect from stopping smoking just before surgery – and a significant positive effect of stopping smoking in the short term.

3.5 Some people who use secondary care services find it difficult to tell healthcare professionals that they smoke, if asked, for fear of disapproval. This is particularly true of pregnant women or people who know or suspect that their illness is related to smoking.

3.6 Current NICE public health guidance 26 on quitting smoking in pregnancy and following childbirth recommends that carbon monoxide (CO) assessments are used to establish exposure of pregnant women to tobacco smoke or other CO sources such as traffic emissions or leaky gas appliances. Many midwives are routinely using CO assessments. Interpretation of the reading can be established through sensitive and non-judgemental discussions with the person to establish smoking status. The PDG felt that CO assessments help monitor smoking and act as a motivational tool for stopping, and identify environmental factors that may cause harm. They also help to identify those at greater risk of adverse, smoking-related outcomes and help with the planning of antenatal care. This non-invasive CO assessment is similar to other common tests that are routinely used in healthcare settings (for example, temperature or blood pressure tests).

3.7 Current NICE public health guidance 26 on quitting smoking in pregnancy and following childbirth recommends that all pregnant women with a CO reading of 7 parts per million (ppm) or above should be referred to stop smoking services. The guidance acknowledges that it is unclear what constitutes the best cut-off point for determining smoking status. The guidance indicates that low levels may go undetected or be undistinguishable from exposure to secondhand smoke and that it is best to use a low cut-off point to avoid missing someone who may need help to quit.

3.8 When this piece of NICE guidance on Smoking cessation in secondary care: acute, maternity and mental health services was put out for consultation it referred to the recommendation from NICE public health guidance 26 on quitting smoking in pregnancy and following childbirth that all pregnant women with a CO reading of 7 ppm or above should be referred. However, several stakeholders commented that the CO assessment cut off for a referral to stop smoking services was too high and should be reduced from 7 ppm to 4 ppm, in line with publications from other organisations. Some PDG members agreed that the level should be reviewed, and felt that future updates of the NICE public health guidance 26 on quitting smoking in pregnancy and following childbirth should address this issue.

3.9 Stop smoking support for healthcare staff is important in its own right. Healthcare staff may find it difficult to admit they smoke or to seek support to help them quit. They may also find it difficult to act as a health champion or to advise people to stop. In addition, the PDG heard evidence that staff who do not smoke are more likely to support hospital smokefree strategies and interventions aimed to help people stop smoking.

3.10 Trials in secondary care that use intensive behavioural interventions to support attempts to stop smoking have been shown to be effective. The effect is significantly increased when nicotine replacement therapy is also offered as part of these interventions. There is relatively little evidence from trials in secondary care that include bupropion or varenicline as a means of helping people to stop smoking. However, these pharmacotherapies are highly effective in trials with the general population, and the PDG felt there was no reason why this would not apply to people in secondary care settings.

3.11 The PDG noted that although stopping smoking is associated with improvements in longer-term mental health, evidence identifies both potential short-term negative and positive effects (such as increased agitation or improvements in mood). Prompt provision of evidence-based treatment can help alleviate negative effects associated with nicotine withdrawal. The PDG also heard evidence that some health and social care practitioners have a limited knowledge and understanding of the specific links between tobacco dependence and mental illness, including the effects of stopping smoking on psychiatric symptoms.

Delivering stop smoking support

3.12 Evidence shows that intensive behavioural support with stop smoking pharmacotherapy delivered during a stay in hospital and continued for at least 4 weeks after discharge is effective. However, this requires coordinating care between hospitals and community services, and routine implementation and post-discharge follow-up is not widespread. The PDG noted the importance of formal systems for recording smoking status and arranging referrals. In addition, rapid response to a referral request, including support provided during a hospital stay, improved service uptake and quit rates.

3.13 The PDG noted that good clinical practice requires clinicians to take a holistic view of patients' physical health, and failing to offer stop smoking treatment is poor practice. The PDG also noted the Department of Health's Make Every Contact Count initiative. This sends a strong message that, given the right support and training, frontline staff are equipped to provide important health messages and refer (or direct) people for further advice and interventions to stop smoking.

3.14 The PDG felt that other health promotion interventions (for example, on alcohol‑related harm or weight management) would ideally be offered at the same time as stop smoking advice, where appropriate. Such activities were, however, beyond the scope of the guidance.

3.15 The PDG considered that healthcare staff should be competent and proactive, but recognised there are barriers to offering stop smoking advice and support. For example, they may have limited time, knowledge and skills, or they may feel that addressing smoking is beyond their role or responsibility. There is also a perception among some that asking about a person's smoking behaviour could damage the staff-patient relationship. The PDG considered that training on how to raise the topic of smoking with people, and when, how and where to refer them for specialist treatment, would overcome these barriers.

3.16 Most smokers will have been encouraged to stop on various occasions. During a quit attempt, they may have found it very difficult to abstain, despite being aware of the harmful effects of continuing to smoke. They may also have stopped in the past but subsequently relapsed. The PDG noted that, in a supportive secondary care environment, where healthcare staff have a positive, non-judgemental attitude, smokers can be encouraged and helped to try again.

3.17 The PDG noted that the role of carers, partners, family and friends is important. They can help to protect people who use secondary care services from secondhand smoke in the home. They can also help with an attempt to stop, by stopping smoking themselves, changing their own behaviour (if they smoke) and providing other support and encouragement.

Smokefree strategies and interventions

3.18 The PDG considered that secondary care providers are more likely to make a strong commitment to smokefree strategies if there is national level support from NHS England and Public Health England.

3.19 The PDG considered evidence from the UK and elsewhere on outcomes after the implementation of smokefree policies. The Group was clear that smokefree policies are self-perpetuating if properly supported and maintained (including through communication, staff training and measures to ensure compliance). The PDG noted that problems arise where smokefree policies are not maintained.

3.20 A total ban on smoking in the buildings and grounds of secondary care services complements the duty of care on healthcare staff and the organisation to protect the health of people in their care and promote healthy behaviour. Furthermore, the PDG felt that the resources needed to support smoking in the grounds would be more suitably directed towards stop smoking support and maintaining a smokefree policy. (Examples of the expense caused by smoking include: the time used for smoking breaks by staff and the erection of smoking shelters.)

3.21 The PDG was concerned that public support for hospital smokefree policies may be diminished if staff are seen smoking in hospital grounds or near entrances. This could give the impression that there is only a low commitment to the smokefree strategy, and could result in visitors dismissing or challenging smokefree policies and related restrictions.

3.22 People who are unable to leave a secondary care setting – for example, when detained under the Mental Health Act or because mobility is restricted – will have to abstain from smoking. Other people using the same service may not be subject to the same restrictions because they are able to leave the building and grounds. The PDG was aware that this situation would need careful and sympathetic management.

3.23 The episodic nature of mental health conditions can impact on a person's ability or willingness to stop smoking. However, in a smokefree secondary care environment, mental health service users will be subject to enforced abstinence – even during an acute phase of illness – and will need help to abstain.

3.24 The PDG heard evidence from UK studies of staff accepting or at times encouraging people to smoke in mental health settings. This could be for a variety of reasons including: as a reward or incentive for good behaviour; to help build relationships or avoid confrontation; as part of a shared smoking culture between staff and people in their care; and to relieve boredom. The PDG noted that helping people to smoke can take up a considerable amount of staff time (for example, when escorting smokers off a ward). It also has an implication in terms of being able to manage the movement of people who are being detained. It considered that these resources could and should be more usefully spent on therapeutic activities for smokers and non-smokers alike. The PDG discussed the need for clear leadership to change this culture. The Group also recognised that this would present many challenges and require significant changes in practice for some mental health services. It also recognised that mental health trusts would need to develop policies and procedures to encourage compliance and resolve any breaches in a variety of local treatment settings (including psychiatric intensive care units and rehabilitation units).

3.25 The PDG heard expert testimony concerning the implementation of smokefree strategies and stop smoking support on a hospital's mental health wards. Before implementation it was identified that a very large proportion of service users (up to 92% on 1 ward) currently smoked, although most of them had previously stopped at some point. Further, many who had previously stopped while at secure institutions where smoking was not permitted started smoking on admission to the hospital. The PDG heard that the following factors played a key role in successful implementation: involving staff and service users in planning and promoting the strategy (such as scoping objectives and creating publicity materials); agreeing individual plans to stop smoking (including risk management); involving primary care providers; reducing boredom through ward plans; encouraging and motivating service users (for example, recognising potential drug dose reductions and financial benefits); providing licensed nicotine-containing products; holding stop smoking groups and planning meetings. Although not recommended, the use of unlicensed nicotine-containing products (such as electronic cigarettes) was allowed. Despite concerns at the outset about the potential negative reactions to smokefree policies, the PDG heard that the number of violent incidents actually reduced.

3.26 The PDG was aware that High Court judges had ruled, in a case involving patients at Rampton high-security hospital where they were not permitted to leave the building to smoke, that patients should not endanger their own (and anyone else's) health by smoking indoors. The judges stated that: 'On the view we take of the evidence, substantial health benefits arise from the ban and the disbenefits are insubstantial'. The judges ruled that both health and security considerations justified the smoking ban even though smoking in the grounds, which might be possible at other hospitals, is not feasible at secure hospitals.

3.27 There is limited evidence on the effectiveness of interventions to help people to temporarily abstain from smoking. However, the PDG agreed that smokers who use secondary care services may need help to comply with national legislation and smokefree policies for hospital buildings and grounds. The same is true of staff and volunteers who smoke.

Unlicensed nicotine-containing products

3.28 Unlicensed nicotine-containing products are being used increasingly by people who smoke to help them stop smoking completely, cut down on smoking, or abstain temporarily from smoking.

3.29 Although unlicensed and of variable quality, safety and effectiveness, these products are expected to be less harmful than smoking. Therefore whilst not actively endorsing the use of unlicensed products, the PDG recognised that some people may find these helpful, either alone or in combination with licensed nicotine-containing products, to support abstinence from smoking. However, some members of the PDG were also concerned by the potential of electronic cigarettes to normalise 'smoking' within a hospital environment.

3.30 The Medicines and Healthcare products Regulatory Agency (MHRA) has decided that all nicotine-containing products should be regulated (for further details, see the MHRA website). This means that there may be a period when both licensed and unlicensed products (such as electronic cigarettes) are being used by the public as a means to abstain from smoking. In this situation, the PDG recognised that it would be very difficult and possibly counterproductive to disallow the use of unlicensed products in all secondary care settings. NHS Trusts would need to formulate their own local policies on the use of such products, depending on local circumstances and judgement.

Economic modelling

3.31 The PDG noted that both the benefits and cost effectiveness of stop smoking interventions for people with mental health problems may be underestimated. One of the most commonly reported measures of quality of life is the EQ-5D. This comprises 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. The PDG considered that this measure was not sensitive to some of the improvements in health arising from stopping smoking. This was of particular concern in relation to measuring the cost effectiveness of stop smoking interventions for people with mental health problems.

3.32 The PDG noted that a number of the benefits of stopping smoking were not included in the economic model. Examples include: a reduction in the harms associated with exposure to secondhand smoke, a reduction in the costs of social care for people with smoking-related diseases, and the effect on the uptake of smoking among children.

3.33 The economic modelling showed that high-intensity stop smoking interventions (including the use of pharmacotherapies) are a highly cost-effective way of helping people to stop smoking. Indeed, many of the interventions assessed were estimated to be cost saving (cheaper and more effective than the comparator).

3.34 The modelling found that interventions are cost effective for different groups with different conditions. This includes: pregnant women, people in secondary care with chronic obstructive pulmonary disease (COPD) and cardiac conditions, pre-operative patients, general patients and hospital employees. The same applies to interventions for people with common mental health problems, such as post-traumatic stress disorder (PTSD). In the case of those with schizophrenia, the interventions showed an effect in the short term. No impact was observed on smoking rates at 12 months. However, based on estimated cost savings made on antipsychotic drugs, if 1 in 10 of these patients quit smoking for a year, the interventions would be cost effective.

3.35 The PDG noted that, as with any modelling exercise, the results are subject to uncertainty and numerous assumptions. However, the sensitivity analysis showed that most interventions remain cost effective, even when the costs and effects of the interventions are randomly varied.

  • National Institute for Health and Care Excellence (NICE)