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05 June 2013

NICE guidance is a world first on helping people who can't stop smoking in one step

Landmark guidance to reduce tobacco-related harm for people who don't feel able to stop smoking in one step is published today by the National Institute for Health and Care Excellence (Wednesday 5 June).

Landmark guidance to reduce tobacco-related harm for people who don't feel able to stop smoking in one step is published today by the National Institute for Health and Care Excellence (Wednesday 5 June).

The NICE public health guidance is the first in the world to recommend that licensed nicotine-containing products can be used to help people to reduce the amount they smoke, especially those who are highly dependent on nicotine. This includes people who may not be able to stop smoking in one go, those who want to stop smoking without necessarily giving up nicotine, and those who might not be ready to stop but want to reduce the amount they smoke.

The best way to reduce the harm from smoking is to stop completely and the best chance of doing this is still to quit in one step. This guidance recognises that for people who've been unable to stop using this standard method, the approaches recommended in this new guidance can help. It could also encourage more people to consider reducing how much they smoke, with the support of licensed nicotine-containing products (such as nicotine replacement therapy (NRT) patches and gum), and advice from stop smoking services, both of which are proven to be effective.

Professor Mike Kelly, Director of the NICE Centre for Public Health, said: “This is the first time anywhere in the world that national guidance will endorse cutting down on smoking with the help of licensed nicotine products, such as patches or gum, as a way to help reduce the harm caused by tobacco. Over 79,000 deaths in England each year are due to smoking tobacco. Put simply, people smoke for the nicotine but die because of the tar in tobacco. However, nicotine inhaled from smoking tobacco is highly addictive, which is why people find it so difficult to stop smoking.

“If you are a smoker, quitting smoking is the best way to improve health, and stopping in one step is most likely to be successful. This guidance recommends harm reduction as an additional new option particularly for those who are highly dependent on smoking who want to quit, but can't just stop in one go.”

Professor Linda Bauld, Chair of the NICE guidance development group, and Professor of Health Policy at the University of Stirling, said: “This guidance provides an important opportunity to reduce the harm associated with smoking tobacco. The cost to the NHS in England of treating smoking-related illnesses is an estimated £2.7 billion a year. One in five adults in England smoke, and around two-thirds of people who smoke say they'd like to quit. People who find it hard to stop smoking in one step are more likely to stop smoking in the longer term if they cut down, and are more likely to successfully stop if they use NRT when they cut down.

“Harm reduction approaches also provide an alternative choice for those who are not currently interested in quitting smoking. Although existing evidence isn't clear about the health benefits of smoking reduction, for some people this reduction can kick-start a gradual change in behaviour that eventually leads them to quit, especially if they use licensed nicotine-containing products. People should ideally do this with support from stop smoking services, but there are also harm reduction options for those not using services. The key thing is to take action to reduce the harm that smoking tobacco causes, and this guidance provides people with new choices about how to do that.”

Chief Medical Officer, Professor Dame Sally Davies, said: "Smokers are harmed by the deadly tar and toxins in tobacco smoke, not necessarily the nicotine they're addicted to. The best thing smokers can do for their health is quit, but if they're not able or ready to then using safer sources of nicotine instead of smoking is much better. Smokers can get help to quit from local Stop Smoking Services. Quitting with help of these services significantly increases your chances of quitting for good."

The NICE recommendations include:

  • Organisations responsible for tackling tobacco use, such as stop smoking services and local authorities, should provide public information which highlights that licensed nicotine-containing products are an effective way of reducing the harm from tobacco for both the person smoking and those around them
  • Stop smoking advisers and health professionals should advise people to stop smoking in one step, but for those who aren't ready or are unable to stop in one step, suggest considering a harm-reduction approach
  • Advisers and health professionals should offer all types of licensed nicotine-containing products to people who smoke, as part of a harm-reduction strategy, either singly or in combination, according to the individual's preference and level of dependence. For example, patches could be offered with gum or lozenges. Advise people that using more than one product is more likely to be successful particularly for more dependent smokers
  • Advisers should discuss reduction strategies, which may include increasing the time interval between cigarettes, delaying the first cigarette of the day or choosing periods during the day, or specific occasions, when the person will not smoke. Follow up appointments to review progress should also be offered
  • Tobacco retailers and retailers of licensed nicotine-containing products should display licensed nicotine-containing products in shops and supermarkets, and on websites selling cigarettes and tobacco products
  • Health professionals and advisers should explain to people how to use licensed nicotine-containing products correctly to control cravings, prevent compensatory smoking when trying to stop smoking or reduce the amount they smoke. They should also reassure them that it is better to use these products and reduce the amount they smoke than to continue smoking at their current level
  • Advisers should tell people who smoke that some nicotine-containing products (for example, electronic cigarettes and topical gels) are not currently regulated by the Medicines and Healthcare products Regulatory Agency and so their effectiveness, safety and quality can't be assured. Also advise them that these products are likely to be less harmful than cigarettes.

Professor Paul Aveyard, NICE guidance developer, GP and Professor of Behavioural Medicine at the University of Oxford said: “Giving up smoking is one of the hardest things a smoker will ever do. Some may not be ready to give up smoking in one step, but half of all smokers say that they want to cut down. Smoking tobacco harms not only the smoker, but also people around them, with children being particularly vulnerable to second-hand smoke.

“Advisors should reassure people that licensed nicotine-containing products are a safe and effective way of reducing the harm from cigarettes, and that NRT products have been shown in trials to be safe for at least 5 years' use. Whatever approach people wish to try, they should be advised that there are no circumstances when it is safer to smoke than to use licensed nicotine containing products and experts believe that lifetime use of these products will be considerably less harmful than smoking.”

Dan Griffin, who has smoked for many years and has tried to stop smoking on several occasions, said: “I've smoked my entire adult life and have tried a number of times to give it up. Some people don't consider smoking an addiction, but I believe it is. If it was really that easy to give up, like many I would have done so long before now. This new approach to help smokers cut down on their smoking, hopefully with a view for some to quitting completely, will be a significant help, particularly for those who have found it hard to stop. It may even encourage some people to ask their GPs for advice who might not have thought about it all that seriously before.”


For more information call Dr Tonya Gillis at the NICE press office on 020 7045 2174 or 0845 003 7782, or out of hours on 07775 583 813.

Notes to Editors

About the NICE guidance, ‘Tobacco: harm-reduction approaches to smoking'

1. The guidance ‘Tobacco: harm-reduction approaches to smoking' is available at from Weds 5 June. Please contact the NICE Press Office for an embargoed copy of the guidance.

2. Further quotes supporting the new guidance:

Professor John Britton, chair of the Royal College of Physicians' tobacco advisory group and NICE guidance developer, said: ‘We welcome this new guidance from NICE, which puts into practice many of the proposals put forward by the RCP in its report on harm reduction in nicotine addiction in 2007. Smokers smoke for nicotine, and since tobacco smoke is by far the most harmful available source of nicotine, switching to alternatives as a short- or long-term substitute is the obvious healthier choice. We would encourage all smokers to take up the opportunities presented by this guidance, and if they can't quit using nicotine altogether, to switch as much as they can to an alternative nicotine product. This guidance has the potential to change millions of lives for the better. We commend it.”

Sarah Woolnough, Cancer Research UK's executive director of policy, said:“Cancer Research UK welcomes the latest NICE guidance on tobacco harm reduction and the use of nicotine containing products (NCPs). Smoking still accounts for one in four cancer deaths and nearly a fifth of all cancer cases, so helping those smokers who want to quit or reduce the harm from smoking remains vital.

“While stopping smoking in one go is most likely to be successful, the use of licensed nicotine containing products provide a useful addition to the smoker's quitting tool-kit, and we support ready access to these products for people wishing to cut down or stop smoking. We believe the NICE guidance will help smokers get the right support and advice in using these products.”

Gretel Baron, smoking cessation adviser with the Roy Castle Lung Cancer Foundation and NICE guidance developer said: “As an ex-smoker myself I know how difficult it can be to stop smoking for good, but it is achievable, particularly with the help of a trained stop smoking adviser. However, I find that some smokers are reluctant to come and see me because they believe that I will ask them to give up cigarettes in one go, and fear that they won't be welcome in the service if they don't succeed with this approach. This guidance gives smokers and services more options, and I believe it will help more people to stop smoking in the longer term.”

Deborah Arnott, chief executive of health charity ASH, said: “To quit smoking completely is always the best option for smokers and success rates are much higher if they get help from the Stop Smoking Services which provide both counseling and medications. However, the new NICE guidance offers evidence-based alternatives for those who are unable to quit abruptly which have been shown to help such as cutting down, smoking less or switching to alternative licensed nicotine products.”

3. This guidance recommends harm-reduction approaches which may or may not include temporary or long-term use of licensed nicotine-containing products. The options addressed in this guidance are:

  • Stopping smoking, but using one or more licensed nicotine-containing products as long as needed to prevent relapse
  • Cutting down prior to stopping smoking (cutting down to quit)
    • with the help of one or more licensed nicotine-containing products (the products may be used as long as needed to prevent relapse)
    • without using licensed nicotine-containing products.
  • Smoking reduction
    • with the help of one or more licensed nicotine-containing products (the products may be used as long as needed to prevent relapse)
    • without using licensed nicotine-containing products.
  • Temporary abstinence from smoking
    • with the help of one or more licensed nicotine-containing products
    • without using licensed nicotine-containing products.

The use of products containing tobacco as a means of ‘harm reduction' is outside the scope of this guidance. This means that ‘reduced exposure cigarettes' and ‘smokeless tobacco' are excluded.

Evidence shows that reductions in smoking without the support of a nicotine replacement product are unlikely to yield any health benefits because of compensatory smoking (such as inhaling more deeply).

Although existing evidence is not clear about the health benefits of smoking reduction, those who reduce the amount they smoke are more likely to stop smoking eventually, particularly if they are using licensed nicotine-containing products.

4. For people cutting down to quit, or reducing the amount they smoke, using licensed NRT products are likely to reduce compensatory smoking behaviour, such as inhaling smoke more deeply.

5. The guidance notes that stop smoking services provide highly cost-effective interventions to help people stop smoking (see NICE guidance on smoking cessation services, PH10) and any investment in the harm-reduction approaches covered by this guidance should not detract from their provision. Rather, the recommendations in this guidance are intended to support and extend the reach and impact of existing services.

6. Licensed nicotine-containing products have been given marketing authorisation by the Medicines and Healthcare products Regulatory Agency (MHRA) for use as a smoking cessation aid and for tobacco harm reduction. Authorisation by the MHRA ensures they are effective, deliver nicotine safely and are manufactured to a consistent quality. Currently, nicotine replacement therapy (NRT) products are the only type of licensed nicotine-containing product. They include: transdermal patches, gum, inhalation cartridges, sublingual tablets and a nasal spray.

7. Other nicotine-containing products, such as electronic cigarettes and topical gels, were not covered by MHRA regulation at the time of publication of the guidance. An MHRA decision is expected in spring 2013 (

8. 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 (NHS Information Centre 2012). The overall financial burden to society has been estimated at £13.74 billion a year. This includes both NHS costs and loss of productivity due to illness and early death (Nash and Featherstone 2010).

9. People from routine and manual occupational backgrounds are almost twice as likely to smoke as those from managerial or professional backgrounds (27% versus 13%) (NHS Information Centre 2012). In 2010, those aged 20-24 and 25-34 reported the highest prevalence of cigarette smoking (28% and 26% respectively, NHS Information Centre, 2012). A third (33%) of people with mental health problems (McManus et al. 2010) and more than two-thirds (70%) of patients in psychiatric units smoke tobacco (Jochelson and Majrowski 2006).

10. Most people attempt to quit without help. But only around 4% who quit without using behavioural or pharmacological therapy are successful for a year or longer (Hughes et al. 2004). This compares to about 15% of those who quit using the NHS Stop Smoking Service (Ferguson et al. 2005).

11. This guidance does not cover pregnant women and maternity services.

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

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