This quality standard covers ways of reducing harm from smoking. In particular, this includes people who are highly dependent on nicotine and who may not be able (or want) to stop smoking in one step, who may want to stop smoking without giving up nicotine, who may want to reduce the amount they smoke without stopping, or who want to abstain temporarily from smoking.

The quality standard does not cover pregnant women or maternity services. Quality statement 5 in the NICE quality standard on antenatal care sets out the high‑quality requirements for ensuring that pregnant women who smoke are referred to an evidence‑based 'stop smoking' service.

The quality standard should also be read alongside the NICE quality standards on smoking cessation: supporting people to stop smoking and smoking: reducing tobacco use.

For more information see the smoking: harm reduction topic overview.

NICE quality standards focus on aspects of health and social care that are commissioned locally. Areas of national policy, such as national awareness campaigns, are therefore not covered by this quality standard.

Why this quality standard is needed

Tobacco smoking remains the single greatest cause of preventable illness and early death in England, accounting for 79,100 deaths among adults aged 35 and over in 2011. Smoking causes the majority of lung cancer cases in the UK (and is linked to many other cancers) as well as accounting for deaths from chronic obstructive pulmonary disease (COPD) and cardiovascular disease. Smoking has implications not just for the smoker, but also for those around them through second‑hand smoke.

Although the prevalence of smoking in the adult population in Great Britain shows a generally downwards trend, almost 20% of adults still smoke (Statistical bulletin: Adult Smoking Habits in Great Britain, 2013 Office for National Statistics). In addition, decreases have not been uniform across all groups. People from routine and manual occupational backgrounds are almost twice as likely to smoke as people from managerial or professional backgrounds. Nearly half of unemployed people and the majority of prisoners and homeless people smoke. Smoking levels are twice the national average in people with mental health problems, and remain relatively high in some groups, including lesbian, gay, bisexual and transgender (LGBT) people.

The best way to reduce illness and death associated with smoking is to stop. In general, stopping smoking in one step (sometimes called 'abrupt quitting') offers the best chance of lasting success (see the NICE guideline on smoking cessation). However, not everyone who smokes is able or wants to stop smoking. For such people, a harm‑reduction approach to smoking could be an option, which may involve the continued use of nicotine.

It is important to extend the reach of harm‑reduction approaches as widely as possible, particularly to people who would not necessarily consider using existing 'stop smoking' services. This may involve using contacts between people who smoke and healthcare practitioners to raise the possibility of using a harm‑reduction approach. As stated in the Department of Health's (2012) report on The NHS's role in the public's health, healthcare professionals should 'make every contact count' by using every contact made with a person as an opportunity to maintain or improve their mental and physical health and wellbeing.

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

  • consumption of tobacco‑containing products

  • cotinine levels in children via exposure to tobacco smoke

  • life expectancy at 75

  • smoking prevalence (all ages)

  • smoking‑related hospital admissions

  • smoking‑related morbidity

  • smoking‑related mortality.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for 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:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 Public health outcomes framework for England, 2013–16


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


2.9 Smoking prevalence – 15 year olds (Placeholder)

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* (NHSOF 1.6i)

4.3 Mortality rate from causes considered preventable ** (NHSOF 1a)

4.4 Under 75 mortality rate from cardiovascular diseases (including heart disease and stroke)* (NHSOF 1.1)

4.5 Under 75 mortality rate from cancer* (NHSOF 1.4i)

4.7 Under 75 mortality rate from respiratory diseases* (NHSOF 1.2)

4.9 Excess under 75 mortality rate in adults with serious mental illness* (NHSOF 1.5)

4.12 Preventable sight loss

* Indicator shared with the NHS Outcomes Framework (NHSOF).

** Complementary to indicators in the NHS Outcomes Framework

Table 2 NHS Outcomes Framework 2015–16


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*

i One‑ and ii Five‑year survival from all cancers

iii One‑ and iv Five‑year survival from breast, lung and colorectal cancer

Reducing premature death in people with mental illness

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

ii Excess under 75 mortality rate in adults with common mental illness

Reducing deaths in babies and children

1.6 i Infant mortality*

Alignment across the health and social care system

* Indicator shared with Public Health Outcomes Framework (PHOF)

Patient and service user experience and safety issues

NICE has developed guidance and associated quality standards on patient experience in adult NHS services and service user experience in adult mental health services (see the NICE pathways on patient experience in adult NHS services and service user experience in adult mental health services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and are supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that impact on service user experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for smoking: harm reduction specifies that services should be commissioned from and coordinated across all relevant agencies involved in helping people to reduce harm from smoking. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to people who smoke.

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 a high‑quality harm‑reduction service for people who smoke 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 working with people who smoke 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 source 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 supporting people who smoke. If appropriate, health, public health and social care practitioners should ensure that family members and carers are involved in the decision‑making process.