NICE says hospitals have a duty of care to help all patients who smoke to quit

NICE, the health and social care guidance body, says in new guidance that all NHS hospitals and clinics should become completely smoke-free to help all patients who smoke, including those receiving mental health treatment, to stop smoking whilst they receive care, and preferably help them to stop for good.

Public health guidance published today (Weds 27 November) by the National Institute for Health and Care Excellence sets out clearly how to help people using acute, maternity and mental health services to stop smoking. The new guidance makes a range of recommendations on effective actions including promoting cessation in advance of planned admissions, immediate provision of smoking cessation drugs and behavioural support after admission to hospital, and making all NHS secondary care settings completely smoke-free.

A huge toll of disease is caused by smoking - including heart disease, cancers and respiratory diseases - costing the NHS and wider society billions of pounds each year. Smoking is responsible for over 460,000 hospital admissions in England each year, and is the biggest avoidable cause of inequalities in health. Smoking in pregnancy causes up to 5000 miscarriages and stillbirths each year, and increases the risk of premature birth and low birth weight. In children, second-hand smoke causes cot death, middle ear disease and exacerbation of asthma. Smoking is especially common among people with mental health problems: whilst 1 in 5 of the general population smokes, the figure rises to 1 in 3 among people with longstanding mental illness and rockets to 70% of people in psychiatric units.

Commenting on the new guidance, Professor Mike Kelly, Director of the NICE Centre for Public Health said: "Smoking is the most important health problem facing the NHS. It's the leading cause of premature death in England - nearly 80,000 lives are lost each year due to smoking. Treating smoking-related illnesses costs the NHS around £2.7bn each year, and costs society an estimated £13.7bn a year. So it's a no brainer, we must deal with the problems caused by smoking.

"NHS hospitals and staff have a duty of care to protect the health of people who use or work in their services. The guidance is clear that this responsibility should cover routinely giving stop smoking support to all patients and staff who smoke, as part of providing advice on how to improve health. Importantly, this includes mental health patients who too often don't get help to stop smoking when attending clinics or hospitals, despite their smoking rate being over 50% higher than the general population.

"We need to end the terrible spectacle of people on drips in hospital gowns smoking outside hospital entrances. This guidance can help make that contradiction a thing of the past by supporting hospital smokefree policies to make NHS secondary care an exemplar for promoting healthy behaviour."

The guidance is for all healthcare professionals in acute, maternity and mental health settings, with some recommendations also for staff in primary care. The recommendations include:

  • Provide everyone with verbal and written information about the hospital's smokefree policy before their appointment, procedure or hospital stay, including short and long-term benefits of stopping smoking and details of the support available to help them stop smoking before, during and after their stay or visit
  • Provide intensive support for people using secondary care services, including discussing past and current smoking behaviour and developing a personal stop smoking plan. Provide immediate access to licensed nicotine containing products (for example, nicotine replacement therapy patches or gum) or other pharmacotherapies. Alert the person's healthcare providers or prescribers to changes in smoking behaviour as other drug doses may need adjusting
  • Provide relatives, carers, friends and other visitors with information about the risks of smoking and secondhand smoke. This should include advice not to smoke near the patient, pregnant woman, mother or child, and not in the house or car. Offer people who want to stop or reduce smoking a referral to a stop smoking service. Explain to visitors that smoking is not allowed on the premises. Direct people to places on site or in the hospital where they can buy nicotine replacement therapies
  • For people using acute, maternity and mental health services, as part of the intensive stop smoking support provided, offer measurements of exhaled carbon monoxide (CO) during each contact, to provide feedback on progress and increase their motivation to stop completely
  • Assign a clinical or medical director to lead on stop smoking support and the smokefree policy for the organisation. Promote stop smoking support for patients and staff and prohibit staff-facilitated smoking breaks and the sale of tobacco products in secondary care settings. Ensure smokefree plans include the removal of shelters or other designated outdoor smoking areas, and that staff, contractor or volunteer contracts do not allow smoking during working hours or when in uniform or on hospital business.

Professor John Britton, Chair of the NICE guidance development group and Director, UK Centre for Tobacco and Alcohol Studies, University of Nottingham said: "As a respiratory doctor, I see the victims of illness and death caused by smoking every working day - and smoking is a major cause of people coming into hospital in the first place. That's why this new guidance is important - stopping smoking is essential to current and future health and hospitals have a vital role in helping smokers to quit. Doctors, nurses and other health staff are accustomed to detecting and treating other life-threatening problems such as diabetes and high blood pressure, but helping people to stop smoking is one of the most cost-effective things that the medical profession can do. We want to see a change of culture in NHS secondary care settings, to make smoking history".

Angela Lomax, a patient who stopped smoking with help from her local hospital, said: "I'd smoked for 40 years when I collapsed with fluid on my lung, and was admitted to the Royal Bolton Hospital as an emergency. I was in hospital for two weeks, and the nurses gave me patches so that I wouldn't have problems with cravings. I didn't smoke the whole time I was in hospital but I did start again when I was discharged. But soon after I got home, I had a call from Helen, the Stop Smoking Advisor. I started seeing her every week, and with her help I gave up for good in July this year about two months after I'd first had support in hospital. I feel so much healthier now. I never would have given up without the help that I've had, so I hope that now other patients will also get the chance to quit smoking for good."

People are already required by law not to smoke inside enclosed or mostly enclosed buildings, but in mental health units patients are often allowed to smoke in the hospital grounds. Most of the reduction in life expectancy among people with serious mental illness is attributable to smoking, and smoking increases the dose requirements of psychotropic drugs and therefore the costs, by an estimated £40 million per year across the UK. Research shows that people with mental health problems who smoke want to give up as much as any other smoker, but they are less likely to be offered help to quit, and smokefree policies aren't well supported by mental health staff.

Welcoming the NICE guidance, Professor Sue Bailey OBE, President of the Royal College of Psychiatrists, said: "There is a common but mistaken belief among some mental health professionals that it's alright for patients in their care to smoke. This is wrong. Patients with mental health problems are far more likely to smoke than the general population, they suffer disproportionately higher rates of physical illnesses, and they die earlier. It's a disgrace that this section of our NHS patient population is left to suffer the consequences of smoking. This means that mental health patients should be given help to stop smoking when they are at outpatients' clinics or admitted to hospital. Providing treatment for a patient's mental health needs, especially in a crisis situation, is a priority, but there will be other opportunities to discuss stop smoking support as an essential part of the duty of care for that patient. I hope that mental health professionals across the NHS will use this new NICE guidance to help improve their patients' health by offering stop smoking support."

Mary Yates, Matron at the South London and Maudsley NHS Trust said: "I would like to see people who are admitted to mental health hospitals having the opportunity and support to quit smoking during their admission. Mental health care professionals must be concerned with both the mental and physical health care aspects of the patients they care for. There is no point working hard to help people manage their delusional beliefs systems if patients leave hospital to face a long and painful illness such as cancer and transfer to the care of an oncology team. Having been actively involved in a smoke-free pilot in the South London and Maudsley NHS Foundation Trust, I have seen many patients with serious mental health problems cut down and successfully quit smoking whilst in our care. The new NICE guidance can help to change the culture whereby smoking is acceptable on NHS grounds and make it easier for hospital staff to set a clear example in helping patients to be successful in their attempt to quit smoking for good."

The guidance, Smoking cessation: acute, maternity and mental health services, is available on the NICE website.


For more information call Dr Tonya Gillis at the NICE press office on 0845 003 7782 or out of hours on 07775 583 813.

Notes to Editors

About the guidance

1. The guidance, Smoking cessation: acute, maternity and mental health services, will be available on the NICE website from Wednesday 27 November 2013. Embargoed copies of the guidance are available from the NICE press office on request.

2. Further quotes supporting the new guidance:

Commenting on the new NICE guidance Smoking cessation in secondary care: acute, maternity and mental health services, President of the Royal College of Obstetricians and Gynaecologists (RCOG), Dr David Richmond said: "We welcome this new guidance from NICE; smoking during pregnancy has adverse effects on fetal development and our advice is for pregnant smokers to stop smoking.

"It is the duty of doctors and midwives to ensure that all mothers-to-be are informed of the risks of smoking during pregnancy and they should be offered advice and support to help them give up or abstain.

"This guidance goes a step further by minimising pregnant women's exposure to harmful tobacco fumes in secondary healthcare settings and this includes policies on maintaining a smokefree environment in hospitals."

Paul Jenkins, CEO of the national charity Rethink Mental Illness said: "This new guidance is really important and timely. It is scandalous that so many people with mental illness are currently given no support to stop smoking.

"High rates of smoking are one of the biggest health problems facing people with severe mental illness. Over 40% of all cigarettes smoked in England are smoked by this group and even though more likely to become physically ill, they are less likely to get help to quit. This has to stop. In September, our Lethal Discrimination report showed that 30,000 people with mental illness are dying needlessly each year, due to preventable physical health problems. Smoking plays a massive part in that.

"Hopefully this guidance will help more health professionals to act, so that we can start to reduce the number of people with mental illness dying unnecessarily."

Professor Kevin Fenton, Public Health England's Director of Health and Wellbeing said: "Reducing tobacco-related death and disease is a major priority for Public Health England. Offering help for people to quit in healthcare settings has great potential to improve health among some of our most vulnerable groups. People with mental health problems suffer some of the worst smoking-related problems, and far too many babies are born to mothers who have smoked throughout pregnancy. In this context, the new NICE guidance is extremely welcome and gives a clear steer to improving health and reducing inequalities for those in most need."

Sir Richard Thompson, President of the Royal College of Physicians, said: "As doctors we are especially aware of the harm that smoking causes to health, and the benefits of stopping smoking. Admission to hospital is a particularly important time and opportunity to stop smoking, and hospital, of all places, should be ready and able to help smokers to do so. We welcome this guidance and the RCP will do all it can to ensure that our hospitals become smoke-free."

Stephen Dalton, chief executive of the NHS Confederation's Mental Health Network, said: "The Mental Health Network welcomes the publication of 'Smoking cessation in secondary care' which aims to promote non smoking as the norm for people using acute, maternity and mental health secondary care services.

"We recognise the challenge of implementation but there is a need for a step change in smoking cessation support across primary and secondary care settings to significantly reduce health inequalities. Smoking is a major contributory factor to health inequalities in people with mental health problems. We know people with severe mental illness die up to twenty five years earlier than the general population, often said to be because of increased rates of smoking. We also know that many people with mental health problems want to and can stop smoking with the right support.

"The report recommends commissioning smoke free secondary care services and for strong leadership to promote stop smoking support (for patients and staff) to initiate a cultural change within an organisation. Our recent briefing Smoking and mental health (September 2013) identified the good work some of our members are doing in this area.

"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."

Professor John R Ashton CBE, President of the UK Faculty of Public Health, said: "Tobacco smoking is the greatest cause of preventable illness and premature death in England, and the strong association between smoking and physical and mental ill-health means many using secondary care services are smokers. FPH welcomes this guidance and supports a duty for secondary care services to provide advice on health improvement. This presents an opportunity to use proven cost effective interventions to initiate and support stop smoking attempts and harm reduction strategies - benefiting people of all ages who smoke and use acute, maternity and mental health services."

Dr Myra Stern, National Lead, Stop Smoking Champions at the British Thoracic Society, said: "We warmly welcome this NICE guidance. The clinical evidence about the contribution that stop smoking services can make when used as a treatment is overwhelming. Unfortunately, some hospitals have allowed financial and bureaucratic hurdles to get in the way, but we believe that investing in cessation services pays financial as well as health dividends in the long term. Now is the time for leadership and we urge Trusts and commissioners to make this support available as a priority."

3. Treating smoking-related illnesses cost the NHS an estimated £2.7 billion in 2006 (Callum et al. 2010). The overall financial burden of all smoking to society has been estimated at £13.74 billion a year. This includes both NHS costs and loss of productivity because of illness and early death, as well as other factors (Nash and Featherstone 2010).

4. In England in 2011, an estimated 79,100 adults aged 35 and over died as a result of smoking, accounting for 18% of all deaths. An estimated 462,900 hospital admissions of people from the same age group were attributable to smoking, accounting for 5% of all admissions (Health and Social Care Information Centre 2013).

5. Smoking is linked to between 3000 and 5000 miscarriages every year in the UK (Passive smoking and children. A report by the Tobacco Advisory Group of the Royal College of Physicians, London, 2010).

6. NICE public health guidance applies to England and is not mandatory.

About NICE

The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

Formerly the National Institute for Health and Clinical Excellence, our name changed on 1 April 2013 to reflect our new and additional responsibility to develop guidance and set quality standards for social care, as outlined in the Health and Social Care Act (2012).

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This page was last updated: 17 December 2013