Quality standard


This quality standard is relevant to anyone involved in protecting health and promoting healthy behaviour among children, young people and adults. This includes people working in the NHS, local authorities, education and the wider public, private, voluntary and community sectors.

This quality standard covers reducing tobacco use, including interventions to discourage people from taking up smoking, tobacco control strategies and smokefree policies. It does not cover referral to and delivery of stop smoking services, which are covered by NICE's quality standard on smoking: supporting people to stop. It does not cover harm reduction approaches to smoking, which are covered by NICE's quality standard on smoking: harm reduction. For more information see the topic overview.

This quality standard covers all smoked tobacco products, including shisha, but does not cover smokeless tobacco or tobacco‑free products such as e‑cigarettes or shisha pens.

Why this quality standard is needed

Smoking is the main cause of preventable illness and premature death in England. It is the primary reason for the gap in healthy life expectancy between the rich and the poor.

Smoking contributes to a wide range of diseases, including cancers, respiratory diseases, coronary heart and other circulatory diseases, stomach and duodenal ulcers, erectile dysfunction, infertility, osteoporosis, cataracts, age‑related macular degeneration and periodontitis.

Smoking can cause complications in pregnancy and labour, including ectopic pregnancy, bleeding, premature detachment of the placenta and premature rupture of the membranes. The health risks for babies of mothers who smoke are substantial.

Children who smoke become addicted to nicotine very quickly. They also tend to continue the habit into adulthood. Around two‑thirds of people who have smoked started smoking before the age of 18. The Department of Health's Healthy lives, healthy people: a tobacco control plan for England highlights that it is crucial to reduce the number of young people who start smoking. If young people see smoking as a normal part of everyday life, then they are much more likely to smoke themselves. This illustrates why it is important to alter the acceptance of smoking as a social norm. Recent research in social psychology and behavioural economics suggests that reducing the number of young people who take up smoking is best achieved by influencing the adult world in which they grow up.

Getting people of all ages to quit smoking is crucial in preventing other people from taking up the habit. Therefore this quality standard should be considered alongside NICE's quality standard on smoking: supporting people to stop. Some people may not be ready or may not want to completely give up tobacco or nicotine but may be interested in reducing harm from smoking. This is covered in the NICE quality standard on smoking: harm reduction, and should also be considered alongside this quality standard.

People with a longstanding mental health problem are twice as likely to smoke as those without a mental health problem. Not only is smoking more common in this group but the degree of addiction is greater. Mortality among people with serious mental illness is substantially higher than among the general population, and smoking is one of the factors contributing to this outcome.

This quality standard is expected to contribute to improvements in the following outcomes:

  • smoking prevalence

  • smoking prevalence within routine and manual groups

  • smoking prevalence among children and young people

  • smoking‑related hospital admissions

  • smoking‑related mortality

  • under 75 mortality rate from cardiovascular disease, respiratory disease, cancer

  • life expectancy

  • healthy life expectancy

  • sickness absence.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable quality improvements within a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Table 1 Public health outcomes framework for England, 2013–2016


Objectives and indicators

1 Improving the wider determinants of health


Improvements against wider factors that affect health and wellbeing and health inequalities


1.9 Sickness absence rate

2 Health improvement


People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities


2.1 Low birthweight of term babies

2.3 Smoking status at time of delivery

2.14 Smoking prevalence – adults (over 18s)

4 Healthcare public health and preventing premature mortality


Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities


4.1 Infant mortality*

4.3 Mortality from causes considered preventable**

4.4 Under 75 mortality rate from all cardiovascular diseases*

4.5 Under 75 mortality rate from cancer*

4.7 Under 75 mortality rate from respiratory diseases*

4.12 Preventable sight loss

Aligning across the health and care system

* Indicator complementary with NHS Outcomes Framework

** Indicator shared with NHS Outcomes Framework

Table 2 NHS Outcomes Framework 2014–15


Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1b Life expectancy at 75

i Males ii Females

Improvement areas

Reducing premature mortality from the major causes of death

1.1 Under 75 mortality rate from cardiovascular disease*

1.2 Under 75 mortality rate from respiratory disease*

1.4 Under 75 mortality rate from cancer*

Reducing premature death in people with serious mental illness

1.5 Excess under 75 mortality rate in adults with serious mental illness*

Reducing deaths in babies and young children

1.6 Infant mortality*

Alignment across the health and social care system

* Indicator shared with Public Health Outcomes Framework (PHOF)

Coordinated services

The quality standard for smoking: reducing tobacco use specifies that services should be commissioned from and coordinated across all relevant agencies. An integrated approach to prevention, smoking cessation, harm reduction and shaping social norms is fundamental to reducing tobacco use.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing high‑quality services that contribute to reducing tobacco use in the community are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health, public health and social care practitioners involved in reducing tobacco use in the community should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in reducing tobacco use. If appropriate, professionals should ensure that family members and carers are involved in the decision‑making process about interventions and initiatives that stop people taking up smoking, reduce tobacco use and help people quit completely.