Raising awareness

These recommendations are for people working in public health, and others with tobacco control and providing advice about harm reduction as part of their remit.

1.8.1.

Raise public awareness of the harm caused by smoking and secondhand smoke. Make it clear that smoking causes a range of diseases and conditions including cancer, chronic obstructive pulmonary disease and cardiovascular disease. [2013]

1.8.2.

Provide information on how people who smoke can reduce the risk of illness and death (to themselves and others) by using 1 or more medicinally licensed nicotine-containing products. Explain that they could be used as a partial or complete substitute for tobacco, either temporarily or in the long term. [2013]

1.8.3.

Provide the following information about nicotine:

• smoking is highly addictive mainly because it delivers nicotine very quickly to the brain and this makes stopping smoking difficult
• most smoking-related health problems are caused by other components in tobacco smoke, not by the nicotine
• nicotine levels in medicinally licensed nicotine-containing products are much lower than in tobacco, and the way these products deliver nicotine makes them less addictive than smoking. [2013, amended 2021]

1.8.4.

Provide the following information about the effectiveness and safety of medicinally licensed nicotine-containing products:

• any risks from using medicinally licensed nicotine-containing products are much lower than those of smoking; nicotine replacement therapy (NRT) products have been demonstrated in trials to be safe to use for at least 5 years
• lifetime use of medicinally licensed nicotine-containing products is likely to be considerably less harmful than smoking. [2013]

1.8.5.

Provide information on using medicinally licensed nicotine-containing products, including:

• what forms they take
• how to use them effectively when trying to stop or cut down smoking
• long-term use to reduce the risk of relapsing
• where to get them
• the cost compared with smoking. [2013]

For recommendations on what information to provide about nicotine-containing e-cigarettes, see the section on advice on nicotine-containing e-cigarettes.

Point-of-sale promotion

These recommendations are for manufacturers and retailers of medicinally licensed nicotine-containing products, including tobacco retailers.

1.8.6.

Encourage people who smoke to consider stopping or, if they do not want or are not ready to stop in one go, to consider the harm-reduction approaches outlined in box 1. [2013]

Developers of communications strategies

1.9.1.

Coordinate communications strategies to support the delivery of stop-smoking support, telephone quitlines, school-based interventions, tobacco control policy changes and any other activities designed to help people to stop smoking. [2018]

1.9.2.

Develop and deliver communications strategies about stopping smoking in partnership with the NHS, national, regional and local government and non-governmental organisations. The strategies should:

• Use the best available evidence of effectiveness, such as Cochrane reviews.
• Be developed and evaluated using audience research.
• Use ‘why to’ and ‘how to’ stop messages that are non-judgemental, empathetic and respectful. For example, use testimonials from people who smoke or used to smoke.
• Involve community pharmacies in local campaigns and maintain links with other professional groups such as dentists, fire services and voluntary groups.
• Ensure campaigns are sufficiently extensive and sustained to have a reasonable chance of success.
• Think about targeting and tailoring campaigns towards groups that epidemiological data identify as having higher than average or stagnant rates of smoking, to address inequalities. [2018, amended 2021]

Schools

1.9.3.

Make information on local stop-smoking support easily available to staff and students. Include details on the type of help available and when, where and how to access the services. [2010]

Employers

1.9.4.

Make information on local stop-smoking support easily available at work. Include details on the type of help available and when, where and how to access the services. Publicise these interventions. [2007]

1.9.5.

Be responsive to individual needs and preferences of employees. If feasible, and if there is sufficient demand, provide on-site stop-smoking support. [2007]

1.9.6.

Allow staff to attend stop-smoking support during working hours without loss of pay. [2007]

1.9.7.

Negotiate a smokefree workplace policy with employees or their representatives. This should:

• State whether or not smoking breaks may be taken during working hours and, if so, where, how often and for how long.
• Include a stop-smoking policy developed in collaboration with staff and their representatives.
• Direct people who wish to stop smoking to local stop-smoking support. [2018]

Employees and their representatives

1.9.8.

Encourage employers to provide advice, guidance and support to help employees who want to stop smoking. [2007]

Identifying people who smoke

These recommendations are for health and social care professionals and those providing stop-smoking support or advice (for recommendations about pregnant women see the section on identifying pregnant women who smoke and referring them for stop-smoking support).

1.11.1.

At every opportunity, ask people if they smoke or have recently stopped smoking. [2018]

1.11.2.

If they smoke, advise them to stop smoking in a way that is sensitive to their preferences and needs, and advise them that stopping smoking in one go is the best approach. Explain how stop-smoking support can help. [2018]

1.11.3.

Discuss any stop-smoking aids the person has used before, including personally purchased nicotine-containing products. [2018]

1.11.4.

Offer advice on using nicotine-containing products on general sale, including over-the-counter nicotine replacement therapy (NRT) and nicotine-containing e-cigarettes. [2018]

1.11.5.

If someone does not want, or is not ready, to stop smoking in one go:

• find out about the person’s smoking behaviour and level of nicotine dependence by asking how many cigarettes they smoke – and how soon after waking
• make sure they understand that stopping smoking reduces the risks of developing smoking-related illnesses or worsening conditions affected by smoking
• ask them to think about adopting a harm-reduction approach (see the section on supporting people who do not want, or are not ready, to stop smoking in one go)
• encourage them to seek help to stop smoking completely in the future
• leave the offer of help open and offer support again the next time they are in contact. [2013]

1.11.6.

Record smoking status and all actions, discussions and decisions related to advice, referrals or interventions about stopping smoking. [2018]

1.11.7.

Ask about their smoking status at the next available opportunity. [2013]

Identifying smoking among carers, family and other household members

These recommendations are for anyone who is responsible for providing health and support services (including stop-smoking support) to people using acute, maternity or mental health services.

1.11.8.

At the earliest opportunity, ask if any of the following people smoke:

• partners of pregnant women
• parents or carers of people using acute or mental health services
• anyone else in the household. [2013]

1.11.9.

If partners, parents, other household members and carers do not smoke, give them positive feedback if they are present. [2013]

1.11.10.

If they do smoke:

• encourage them to stop if they are present, and refer them to a hospital or local stop-smoking support using local arrangements if they want to stop or cut down their smoking
• if they are not present, ask the person using services to suggest they contact stop-smoking support and provide contact details. [2013]

1.11.11.

During contact with partners, parents, other household members and carers of people using acute, maternity and mental health services:

• provide clear advice about the danger of smoking and secondhand smoke, including to pregnant women and babies – before and after birth
• recommend not smoking around the patient, pregnant woman, mother or baby (this includes not smoking in the house). [2010]

Advice on medicinally licensed products

These recommendations are for people providing stop-smoking support or advice.

1.12.10.

Emphasise that:

• most smoking-related health problems are caused by other components in tobacco smoke, not by the nicotine
• any risks from using medicinally licensed nicotine-containing products or other stop-smoking pharmacotherapies are much lower than those of smoking. [2013, amended 2021]

1.12.11.

Explain how to use medicinally licensed nicotine-containing products correctly. This includes ensuring people know how to achieve a high enough dose to:

• control cravings
• prevent compensatory smoking
• achieve their goals on stopping or reducing the amount they smoke. [2013]

1.12.12.

Advise people using short-acting NRT to replace each cigarette with the product they are using, for example a lozenge or piece of gum. Ideally, they should use this before the usual time they would have had the cigarette, to allow for the slower nicotine release from these products. [2013]

Advice on nicotine-containing e-cigarettes

These recommendations are for people providing stop-smoking support or advice to adults.

1.12.13.

Give clear, consistent and up-to-date information about nicotinecontaining e-cigarettes to adults who are interested in using them to stop smoking (for example, see the NCSCT e-ciqarette guide and Public Health England’s information on e-ciqarettes and vaping). [2021]

1.12.14.

Advise adults how to use nicotine-containing e-cigarettes. This includes explaining that:

• e-cigarettes are not licensed medicines but are regulated by the Tobacco and Related Products Regulations (2016)
• there is not enough evidence to know whether there are long-term harms from e-cigarette use
• use of e-cigarettes is likely to be substantially less harmful than smoking
• any smoking is harmful, so people using e-cigarettes should stop smoking tobacco completely. [2021]

1.12.15.

Discuss:

• how long the person intends to use nicotine-containing e-cigarettes for
• using them for long enough to prevent a return to smoking and
• how to stop using them when they are ready to do so. [2021]

1.12.16.

Ask adults using nicotine-containing e-cigarettes about any side effects or safety concerns that they may experience. Report these to the MHRA Yellow Card scheme, and let people know they can report side effects directly. [2021]

1.12.17.

Explain to adults who choose to use nicotine-containing e-cigarettes the importance of getting enough nicotine to overcome withdrawal symptoms, and explain how to get enough nicotine. [2021]

Telephone quitlines

1.12.18.

Ensure publicly sponsored telephone stop-smoking quitlines offer a rapid, positive and authoritative response. If possible, give callers whose first language is not English access to information and support in their chosen language. [2018]

1.12.19.

Ensure all staff giving advice through stop-smoking quitlines receive stop-smoking training (at least in brief interventions to help people stop smoking). [2018]

1.12.20.

Train staff who offer counselling through stop-smoking quitlines so that they meet the NCSCT Training Standard (individual behavioural counselling). Preferably, they should also have a relevant counselling qualification. Training should comply with the NCSCT Training Standard for training in smoking cessation treatments or its updates. [2008, amended 2018]

Information on stopping smoking for those using acute, maternity and mental health services

These recommendations are about information and support before any secondary care admission.

1.14.1.

Give people information about the smokefree policy before their appointment, procedure or hospital stay. This should cover:

• the short- and long-term health benefits of stopping smoking at any time; for example, stopping smoking at any time before surgery has no ill effects (although people may experience short-term withdrawal symptoms such as headaches or irritability from quitting), and people who stop in the 8 weeks before surgery can benefit significantly
• the risks of secondhand smoke
• the fact that all buildings and grounds are smokefree so they must not smoke while admitted to, using or visiting these services (see the section on policy)
• the types of support available to help them stop smoking completely or temporarily before, during and after an admission or appointment (see the sections on behavioural support in acute and mental health services and supporting people who have to stop smoking temporarily)
• about the different pharmacotherapies that can help with stopping smoking and temporary abstinence, where to obtain them (including from GPs) and how to use them. [2013, amended 2021]

1.14.2.

Before a planned or likely admission to an inpatient setting, work with the person to include how they will manage their smoking on admission or entry to the secondary care setting in their personal care plan. [2013]

1.14.3.

Encourage people being referred for elective surgery to stop smoking before their surgery. Refer them to local stop-smoking support. [2018]

1.14.4.

Provide information and take the opportunity to provide advice to visitors about the benefits of stopping smoking and how to contact local stop-smoking support. [2013]

Referring to behavioural support in acute, maternity and mental health services

1.14.5.

Offer and, if the person agrees, arrange for them to receive behavioural support to stop smoking during either their current outpatient visit or their inpatient stay. [2013]

1.14.6.

For people using secondary care services in the community, staff trained to provide behavioural support to stop smoking should offer and provide support. Other staff should offer and, if accepted, arrange a referral to local stop-smoking support. [2013]

Behavioural support in acute and mental health services

These recommendations are for healthcare professionals, stop-smoking advisers and others trained to provide behavioural support to stop smoking. For pregnant women, see the section on providing support to stop smoking for pregnant women.

1.14.7.

Discuss current and past smoking behaviour and develop a personal stop-smoking plan as part of a review of the person’s health and wellbeing. [2013]

1.14.8.

Provide information about the different types of stop-smoking options and how to use them. [2013, amended 2021]

1.14.9.

Provide information about the types of behavioural support to stop smoking available. [2013]

1.14.10.

Offer and arrange or supply prescriptions of stop-smoking options (see the sections on stop-smoking interventions and stop-smoking pharmacotherapies in acute and mental health services). [2013, amended 2021]

1.14.11.

Offer to measure people’s exhaled carbon monoxide level during each contact and use these measurements to motivate them to stop smoking and provide feedback on their progress. [2013]

1.14.12.

Alert the person’s other healthcare providers and prescribers to changes in smoking behaviour because dosages of other medicines may need adjusting (see the section on drug dosages for people who have stopped smoking). [2013]

1.14.13.

For people who smoke who are admitted to secondary care, as well as following the recommendations in this section:

• Provide immediate support if necessary, otherwise within 24 hours of admission.
• Provide support (on site) as often and for as long as needed during admission.
• Offer weekly sessions, preferably face to face, for at least 4 weeks after discharge. If it is not possible to provide this support after discharge, arrange a referral to local stop-smoking support. [2013]

1.14.14.

For people who smoke who are receiving secondary care services in the community or at outpatient clinics (including preoperative assessments) follow the recommendations in this section and:

• Provide immediate support at the outpatient site.
• Offer weekly sessions, preferably face to face, for at least 4 weeks after the date they stopped smoking. Arrange a referral to local stop-smoking support if the person prefers. [2013]

Stop-smoking pharmacotherapies in acute and mental health services

For pregnant women, see recommendations on nicotine replacement therapy and other pharmacological support in the pregnancy section.

Also see the recommendations on smoking in the physical health section of NICE’s guideline on psychosis and schizophrenia in adults.

1.14.15.

If stop-smoking pharmacotherapy is accepted, make sure it is provided immediately. [2013]

1.14.16.

Advise people to remove nicotine replacement therapy patches 24 hours before microvascular reconstructive surgery and surgery using vasopressin injections. [2013]

1.14.17.

When people are discharged from hospital, ensure they have enough stop-smoking pharmacotherapy to last at least 1 week or until their next contact with stop-smoking support. [2013]

1.14.18.

Tell them about local policies on indoor and outdoor use of nicotine-containing e-cigarettes. [2013, amended 2021]

See also the section on stop-smoking interventions.

Stop-smoking support in mental health services

1.14.19.

For people with severe mental health conditions who may need additional support to stop smoking, offer:

• delivery by a specialist adviser with mental health expertise
• support that is tailored in duration and intensity to the person’s needs. [2021]

See also the section on stop-smoking interventions.

Supporting people who have to stop smoking temporarily

These recommendations are for health and social care professionals, stop-smoking advisers and voluntary and community organisations.

1.14.20.

For those who need to abstain temporarily to use acute and mental health services:

• tell them about the different types of medicinally licensed nicotine-containing products and how to use them and
• encourage the use of medicinally licensed nicotine-containing products to help them abstain and, if possible, prescribe them. [2013]

1.14.21.

Provide behavioural support alongside medicinally licensed nicotine-containing products to maintain abstinence from smoking while in secondary care. [2013]

1.14.22.

Offer behavioural support to people who want or need to abstain from smoking temporarily in all settings, including closed institutions for example. Support could include:

• one-to-one or group sessions by specialist services
• discussing why it is important to reduce the harm caused by smoking (to others as well as themselves)
• encouraging people to consider other times or situations when they could stop. [2013]

Medicine dosages for people who have stopped smoking

These recommendations are for people who prescribe stop-smoking pharmacotherapies, and for pharmacists, and health and social care professionals in acute, maternity and mental health services (including both inpatient and community mental health services).

1.14.23.

Monitor people’s use of prescribed medicines that are affected by smoking (or stopping smoking) for efficacy and adverse effects. Adjust the dosage as appropriate. Medicines that are affected include: clozapine, olanzapine, theophylline and warfarin. Refer to specific information for individual medicines, such as in the BNF or summaries of product characteristics in the electronic medicines compendium. [2013, amended 2021]

1.14.24.

Discuss with people who use secondary care and their carers that it might be possible to reduce the dose of some prescribed medicines when they stop smoking. Also advise them to seek medical advice if they notice any side effects from changing the amount they smoke. [2013]

Making stop-smoking options available in hospital

These recommendations are for hospital pharmacists and managers.

1.14.25.

Ensure hospital pharmacies stock the medicinally licensed products recommended in the section on stop-smoking interventions for patients and staff. [2013]

1.14.26.

Ensure people using secondary care have access to stop-smoking pharmacotherapies at all times. [2013]

See also recommendation 1.22.14.

Supporting staff in secondary care and closed institutions to stop smoking

These recommendations are for providers of secondary care and stop-smoking support, and managers of closed institutions and other services where smoking is not permitted.

1.14.27.

Advise all staff who smoke to stop. Ensure systems are in place for staff who smoke to receive advice and guidance on how to stop in one go. [2013]

1.14.28.

Encourage staff to use stop-smoking support to stop or cut down the amount they smoke. Provide contact details for community support if preferred. [2013]

See also the section on stop-smoking interventions and the NCSCT’s service and delivery guidance 2014.

Supporting staff in secondary care and closed institutions to reduce their harm from smoking and comply with smokefree policies

These recommendations are for providers of secondary care, and managers of closed institutions and other services where smoking is not permitted.

1.14.29.

For staff in secondary care and closed institutions who do not want, or are not ready, to stop smoking in one go:

• Ask them if they would like to think about reducing the harm from smoking (see box 1).
• Advise them to use medicinally licensed nicotine-containing products to help them not to smoke immediately before and during working hours. Advise them where to get them. [2013]

1.14.30.

Offer and provide behavioural support to help staff in secondary care and closed institutions not to smoke during working hours. [2013]

Choosing a harm-reduction approach

1.15.1.

Advise people that stopping smoking in one go is the best approach. [2013]

1.15.2.

If someone does not want, or is not ready, to stop smoking in one go, ask if they would like to think about reducing the harm from smoking. If they agree, help them to identify why they smoke, their smoking triggers and their smoking behaviour. Use this information to work through the approaches outlined in box 1. [2013]

1.15.3.

Suggest which approaches to stopping smoking might be most suitable, based on the person’s smoking behaviour, previous attempts to stop and their health and social circumstances. Briefly discuss the merits of each approach to help them choose. [2013]

Medicinally licensed nicotine-containing products for harm reduction

These recommendations are for health and social care professionals, stop-smoking advisers and voluntary and community organisations.

1.15.4.

Reassure people who smoke that medicinally licensed nicotine-containing products are a safe, effective way to reduce the amount they smoke or to cut down before stopping. Also:

• advise them that these products can be used as a complete or partial substitute for tobacco, either in the short or long term
• explain that using these products also helps avoid compensatory smoking and increases their chances of stopping in the longer term
• reassure them that it is better to use these products and reduce the amount they smoke than to continue smoking at their current level. [2013]

1.15.5.

Advise people that medicinally licensed nicotine-containing products can be used for as long as they help stop them going back to previous levels of smoking (see box 1). [2013, amended 2021]

1.15.6.

If possible, supply or prescribe medicinally licensed nicotine-containing products. Otherwise, encourage people to ask their GP or pharmacist for them, or tell them where they can buy the products themselves. [2013]

1.15.7.

If more intensive support is needed, refer to stop-smoking support. [2013]

Behavioural support for harm reduction

These recommendations are for stop-smoking advisers and those trained to provide behavioural support to help people stop smoking, including telephone quitlines and internet support sites.

1.15.8.

Use the information gathered about smoking ‘ (see the section on identifying and quantifying people’s smoking) to help people set goals and discuss reduction strategies. This may include:

• increasing the time interval between cigarettes
• delaying the first cigarette of the day
• choosing periods during the day, or specific occasions, when they will not smoke. [2013]

1.15.9.

Help people who are cutting down before stopping smoking to set a specific quit date. Normally this quit date should be within 6 weeks of them starting behavioural support, although the sooner the better. Help them to develop a schedule detailing how much they aim to cut down (and when) in the lead up to that date. [2013]

1.15.10.

Help people who are aiming to reduce the amount they smoke (but not intending to stop) to set a date when they will have achieved their goal. Help them to develop a schedule for this or to identify specific periods of time (or specific events) when they will not smoke. [2013]

1.15.11.

Tell people who are not prepared to stop smoking that the health benefits from reducing the amount they smoke are unclear. But advise them that if they reduce their smoking now, they are more likely to stop smoking in the future. Explain that this is particularly true if they use medicinally licensed nicotine-containing products to help reduce the amount they smoke. [2013]

1.15.12.

If necessary, advise people how to use medicinally licensed nicotine-containing products effectively. [2013]

Harm-reduction self-help materials

1.15.13.

Provide self-help materials in a range of formats and languages, tailored to meet the needs of groups in which smoking is widespread and many people are dependent on tobacco, for example, those listed as being at high risk of harm in the section on commissioning and designing services. [2013, amended 2021]

1.15.14.

Self-help materials for people who smoke should include advice about the areas covered in the section on choosing a harm-reduction approach, as well as details of where to find more help and support. Use social media websites to publicise self-help materials. [2013]

Manufacturer information supplied with medicinally licensed nicotine-containing products

1.15.15.

Provide consumers with clear, accurate information on the health risks of any medicinally licensed nicotine-containing product, compared with continuing to smoke and not smoking. Include details on long-term use. [2013]

1.15.16.

Provide simple, clear instructions on how to use medicinally licensed nicotine-containing products to support the harm-reduction approaches outlined in box 1. [2013]

1.15.17.

Think about providing information on the outer packaging as well as in the enclosed leaflet for medicinally licensed nicotine-containing products. [2013]

1.15.18.

Package medicinally licensed nicotine-containing products in a way that makes it as easy as possible for people to take the recommended dose for the right amount of time. [2013]

Identifying people who use smokeless tobacco and offering referral

These recommendations are for GPs, dentists, pharmacists and other healthcare professionals, particularly those providing services for South Asian communities.

1.16.1.

Ask people if they use smokeless tobacco, using the names that the various products are known by locally. If necessary, use visual aids to show them what the products look like. (This may be necessary if the person does not speak English well or does not understand the terms being used.) Record the outcome in the person’s notes. [2012]

1.16.2.

If someone uses smokeless tobacco, ensure they are aware of the health risks (for example, the risk of cardiovascular disease, oropharyngeal cancers and periodontal disease). Use a brief intervention to advise them to stop. [2012]

1.16.3.

Refer people who use smokeless tobacco who want to quit to local specialist tobacco cessation services (see the section on stop-smoking interventions). This includes services specifically for South Asian groups, where they are available. [2012]

1.16.4.

Record the person’s response to any attempts to encourage or help them to stop using smokeless tobacco in their notes (as well as recording whether they smoke). [2012]

Providing support to stop using smokeless tobacco

These recommendations are for people providing support or advice as part of a comprehensive specialist tobacco cessation service.

1.16.5.

Use the local names when referring to smokeless tobacco products. [2012, amended 2021]

1.16.6.

Provide advice on how to quit to people who use smokeless tobacco (or recommend that they get advice to help them quit). [2012, amended 2021]

1.16.7.

Offer people who use smokeless tobacco help to prevent a relapse after an attempt to stop. If possible, check the success of the attempt by using a cotinine test (saliva examination). Monitor for any possible increase in tobacco smoking or use of areca nut. [2012, amended 2021]

1.16.8.

Advise people on how to cope with the potential adverse effects of quitting smokeless tobacco. This may include, for example, referring people for help to cope with oral pain, as well as providing general support to cope with withdrawal symptoms. [2012, amended 2021]

1.16.9.

Check whether smokeless tobacco users also smoke tobacco and, if that is the case, provide help to quit them both. [2012, amended 2021]

Developing services for people using smokeless tobacco

Supporting people trying to stop smoking

1.17.1.

Discuss ways of preventing a relapse to smoking. This could include talking about coping strategies and practical ways of making it easier to prevent a relapse to smoking. Do this at an early stage and at each contact. [2021]

1.17.2.

Offer the opportunity for a further course of varenicline, NRT or bupropion to prevent a relapse to smoking.

In November 2021, this was an off-label use of bupropion. See NICE’s information on prescribing medicines.

In August 2022, varenicline was unavailable in the UK. See the MHRA alert on varenicline. [2021]

Supporting people cutting down or stopping temporarily

1.17.3.

If people who set out to reduce the amount they smoke or to stop temporarily have been successful, assess how motivated they are to:

• maintain that level
• reduce the amount they smoke even more
• stop completely. [2013]

1.17.4.

At appropriate intervals, measure people’s exhaled breath for carbon monoxide to gauge their progress and help motivate them to stop smoking. Ask them whether daily activities, for example climbing the stairs or walking uphill, have become easier. Use this feedback to prompt discussion about the benefits of cutting down and, if appropriate, to encourage them to cut down even more or stop completely. [2013]

1.17.5.

Offer medicinally licensed nicotine-containing products, as needed, to help prevent a relapse among people who have reduced the amount they smoke. [2013, amended 2021]

Reviewing the approach for people trying to stop smoking, cutting down or stopping temporarily

1.17.6.

For people attempting to stop smoking and those reducing their harm, offer follow-up appointments and review the approach taken at each contact. [2021]

1.17.7.

Encourage people who have not achieved their quitting or harm-reduction goals to try again. Remind them that various interventions are available to help them and discuss which option to use next. See the sections on stop-smoking interventions and on supporting people who do not want, or are not ready, to stop smoking in one go to reduce their harm from smoking. [2021]

Nicotine replacement therapy and other pharmacological support

1.20.6.

Consider NRT alongside behavioural support to help women stop smoking in pregnancy (see BNF information on NRT). [2021]

1.20.7.

Consider NRT at the earliest opportunity in pregnancy and continue to provide it after pregnancy if the woman needs it to prevent a relapse to smoking, including if the pregnancy does not continue (see BNF information on NRT). [2021]

1.20.8.

Give pregnant women clear and consistent information about NRT. Explain:

• that it may help them stop smoking and reduce their cravings
• how to use NRT correctly, including how to get a high enough dose of nicotine to control cravings, prevent compensatory smoking and stop successfully. [2021]

1.20.9.

Advise pregnant women who are using nicotine patches to remove them before going to bed. [2010]

1.20.10.

Emphasise to pregnant women that:

• most smoking-related health problems are caused by other components in tobacco smoke, not by the nicotine
• any risks from using NRT are much lower than those of smoking
• nicotine levels in NRT are much lower than in tobacco, and the way these products deliver nicotine makes them considerably less addictive than smoking. [2021]

1.20.11.

Do not offer varenicline or bupropion to pregnant or breastfeeding women. [2010]

Incentives to stop smoking

These recommendations are for providers of stop-smoking support.

1.20.12.

In addition to NRT and behavioural support, offer voucher incentives to support women to stop smoking during pregnancy, as follows:

• refer women to an incentive scheme at the first maternity booking appointment or at the next available opportunity
• provide vouchers only for abstinence validated using a biochemical method, such as a carbon monoxide test with a reading of less than 4 ppm
• stagger incentives until at least the end of pregnancy (incentives totalling around £400 have been shown to be effective)
• do not exclude women who have relapsed or those whose pregnancy does not continue from continuing to take part in the scheme and try again
• ensure vouchers cannot be used to buy products that could be harmful during pregnancy (for example, alcohol and cigarettes). [2021]

1.20.13.

Consider providing voucher incentives jointly to the pregnant woman and to a friend or family member that she has chosen to support her during her quit attempt. [2021]

1.20.14.

Ensure staff are trained to promote and deliver incentive schemes to pregnant women to stop smoking. [2021]

Enabling all pregnant women to access stop-smoking support

These recommendations are to help providers of stop-smoking support reach all pregnant women, including those whose circumstances may make it more difficult to use services (for example, because of cultural or sociodemographic factors, age or language).

1.20.15.

Involve pregnant women who find it difficult to use or access existing stop-smoking support in the planning and development of services. [2010]

1.20.16.

Collaborate with the family nurse partnership and other outreach schemes to identify additional opportunities for providing intensive and ongoing support to pregnant women to stop smoking. (Note: family nurses make frequent home visits.) [2010]

1.20.17.

Work in partnership with agencies that support pregnant women who have complex social and emotional needs. This includes substance misuse services, youth and teenage pregnancy support and mental health services. [2010]

Helping partners and others in the household who smoke

These recommendations are for providers of stop-smoking support. See also the section on identifying smoking among carers, family and other household members.

1.20.18.

Offer pregnant women’s partners who smoke help to stop. Use an intervention that comprises 3 or more elements and multiple contacts. Discuss with them which options to use – and in which order, taking into account:

• their preferences
• contraindications and the potential for adverse effects from stop-smoking pharmacotherapies
• the likelihood that they will follow the course of treatment
• their previous experience of stop-smoking aids
• do not favour one course of treatment over another; together, choose the one that seems most likely to succeed taking into account the above. [2010]

Communicating the smokefree policy

1.21.5.

Develop, deliver and maintain a communications strategy on local smokefree policy requirements. This could include newsletters, pamphlets, posters and signage (smokefree signs for vehicles or areas that are enclosed or substantially enclosed must comply with regulations under the Health and Safety at Work etc Act 1974). Include information for people who use secondary care services, their parents or carers, staff and visitors, and the wider local population. Also include:

• clear, consistent messages about the need to keep buildings and grounds smokefree
• positive messages about the health benefits of a smokefree environment
• the fact that health and social care professionals have a duty to provide a safe, healthy environment for staff and people who use or visit secondary care services
• information about stop-smoking support and how to access services, including support to temporarily stop, for staff and people who use secondary care services
• the fact that staff are not allowed to smoke at any time during working hours or when recognisable as an employee, contractor or volunteer (for example, when in uniform, wearing identification, or handling hospital business). [2013]

Closed institutions

1.21.6.

Include management of smoking in the care plan of people in closed institutions who smoke. [2013]

1.21.7.

Develop a policy to ensure effective stop-smoking interventions are provided and promoted in prisons, military establishments and long-stay health centres, such as mental healthcare units. Use Department of Health and Social Care guidance to develop the policy. [2018]

See also the sections on employers, support to stop smoking in secondary care services and supporting people who do not want, or are not ready, to stop smoking in one go to reduce their harm from smoking.

Ensuring local tobacco control strategies include secondary care

These recommendations are for people with responsibility for planning, commissioning and running tobacco control strategies.

1.21.8.

Ensure the joint strategic needs assessment:

• takes into account the impact of smoking on local communities
• identifies expected numbers of particular groups of people who are at very high risk of tobacco-related harm (for example, those listed as being at high risk of harm in the section on commissioning and designing services)
• identifies the proportion of people at very high risk reached by services and the numbers who successfully stop smoking. [2013]

1.21.9.

Make it clear in the local tobacco control strategy that people working in secondary care should:

• communicate key messages about tobacco-related harm to everyone who uses services
• develop policies and support to help people stop smoking
• identify people who want to stop smoking and, if appropriate, refer them to a stop-smoking adviser
• implement a comprehensive smokefree policy that includes the grounds of the establishment. [2013]

1.21.10.

Develop a local stop-smoking care pathway and referral procedure to ensure there is continuity of care between primary, community and secondary care. [2013]

Providing stop-smoking support to employers

1.22.5.

Offer support to employers who want to help their employees to stop smoking. If appropriate and feasible, provide support on the employer’s premises. [2007]

1.22.6.

If initial demand exceeds the resources available, focus on the following:

• small and medium-sized enterprises
• enterprises with a high proportion of employees on low pay
• enterprises with a high proportion of employees at high risk of tobacco-related harm. [2007]

Harm reduction within stop-smoking support

1.22.7.

Ensure investment in harm-reduction approaches does not detract from, but supports and extends the reach and impact of, existing stop-smoking support. [2013]

1.22.8.

Develop stop-smoking referral and treatment pathways to ensure a range of approaches and interventions is available to support people who opt for a harm-reduction approach (see box 1). [2013]

1.22.9.

Ensure service specifications require providers of stop-smoking support to offer medicinally licensed nicotine-containing products on a long-term basis to help people maintain a lower level of smoking. [2013, amended 2021]

Stop-smoking support in secondary care

1.22.10.

Ensure all secondary care buildings and grounds are smokefree. [2013]

1.22.11.

Ensure the NHS standard contract and local authority contract includes smokefree strategies. [2013]

1.22.12.

Ensure all hospitals have on-site stop-smoking support. [2013]

1.22.13.

Ensure stop-smoking medicinally licensed products are included in secondary care formularies. [2013]

1.22.14.

Include NICE-recommended nicotine-containing products as options for sale in secondary care settings (for example, in hospital shops). [2021]

1.22.15.

Ensure secondary care service specifications and service-level agreements require:

• all staff to be trained to give advice on stopping smoking and to make a referral to behavioural support
• relevant staff to undertake regular continuing professional development in how to provide behavioural support to stop smoking. [2013]

1.22.16.

Monitor and audit the implementation and impact of recommendations for secondary care services. This may include recording:

• individual smoking status (including for pregnant women at the time of giving birth)
• number of referrals
• uptake of interventions
• prescribing of stop-smoking pharmacotherapies
• 4-week quit rates
• staff training.
  Ensure the needs of higher-risk groups identified in the joint strategic needs assessment are being met (see the section on ensuring local tobacco control strategies include secondary care). [2013]

1.22.17.

Ensure secondary care providers have enough resources to maintain a smokefree policy. [2013]

1.22.18.

Ensure secondary care pathways cover the following actions:

• identifying people who smoke
• providing advice on likely smoking-related complications
• providing advice on how to stop smoking
• proactively referring people to stop-smoking support. [2013]

1.22.19.

Secondary care directors and managers leading on stop-smoking support should assign a clinical or medical director to lead on stop-smoking support for people who use, or work in, secondary care services. As well as implementing the recommendations in this guideline on providing and commissioning stop-smoking support in secondary care, the designated lead should ensure:

• the organisation has an annual improvement programme for stop-smoking support given to people who use, or work in, secondary care services
• stop-smoking support (for patients and staff) is promoted and communicated effectively (see the section on communicating the smokefree policy) to start a cultural change within the organisation
• the quality of stop-smoking support continues to improve
• performance monitoring and feedback on outcomes is provided to all staff. [2013]

Referral systems for people who smoke

1.22.20.

Ensure there are systems for consistently recording and maintaining records of smoking status. All patient records should:

• provide a prompt for action (including referral to stop-smoking support)
• be stored for easy access and audit. [2013]

1.22.21.

Make sure there is a robust system (preferably electronic) to support continuity of care between secondary care and local stop-smoking support for people moving in and out of secondary care. [2013]

Monitoring stop-smoking services by commissioners and managers

1.22.22.

Set targets for stop-smoking services, including the number of people using the service and the proportion who successfully stop smoking. Performance targets should include:

• treating at least 5% of the estimated local population who smoke each year
• achieving a stop-smoking rate of at least 35% at 4 weeks, based on everyone who starts treatment and defining success as not having smoked (confirmed by carbon monoxide monitoring of exhaled breath) in the fourth week after the quit date. [2018]

1.22.23.

Check self-reported smoking abstinence using a carbon monoxide test. Define success as the person having less than 10 parts per million (ppm) of carbon monoxide in their exhaled breath at 4 weeks after the quit date. This does not imply that treatment should stop at 4 weeks. [2018]

1.22.24.

Monitor performance data for stop-smoking services routinely and independently. Make the results publicly available. [2018]

1.22.25.

Audit exceptional results (for example, 4-week smoking quit rates lower than 35% or above 70%). Use the audit to determine the reasons for unusual performance as well as to identify good practice and ensure it is being followed. [2018]

1.22.26.

Assess the performance of providers that support people who want to reduce the harm from smoking. Additional measures could include:

• numbers attending the services (for comparison with the numbers attending before harm-reduction options were offered)
• classifying the harm-reduction approaches used (see box 1)
• characteristics of people using the service (such as demographic data, cigarette usage, level of dependency and previous attempts to stop)
• type and amount of medicinally licensed nicotine-containing products supplied or prescribed, and over-the-counter sales of these products
• number of people setting a quit date. [2013]

Training to prevent uptake of smoking

This recommendation is for those with responsibility for improving the health and wellbeing of children, young people and young adults who attend school.

1.23.1.

Work in partnership with those involved in smoking prevention and stop-smoking activities to design, deliver, monitor and evaluate smoking prevention training and interventions. Partners could include:

• national and local education agencies
• training agencies
• local authorities
• tobacco control alliances
• school nursing service
• voluntary sector organisations
• local health improvement services
• providers of stop-smoking support
• universities. [2010]

See also NICE’s guidelines on behaviour change: general approaches and alcohol interventions in secondary and further education.

Training on stopping smoking

1. Health effects of e-cigarettes

What are the short- and long-term health effects of e-cigarette use? Are there any specific health effects relating to use in pregnancy, or use by children and young people? [2021]

2. Nicotine replacement therapy and e-cigarettes and pregnancy

Are nicotine replacement therapy or nicotine-containing e-cigarettes effective to help women stop smoking in pregnancy (and at what dose)? [2021]

3. Stop-smoking interventions for under-served groups

How can effective and cost-effective interventions to support people to stop smoking be modified to improve engagement with and accessibility for under-served groups? How acceptable are these interventions to these groups? [2021]

4. Support for people with mental health conditions to stop smoking

How can people with mental health conditions be supported effectively to stop smoking (at individual and system level)? What are the challenges and opportunities and how can they be addressed? [2021]

5. E-cigarettes and pregnancy

What are the views and concerns of:

• pregnant women who smoke
• the healthcare professionals who care for them

6. E-cigarettes for harm reduction

Are nicotine-containing e-cigarettes effective and safe for harm reduction when used alongside tobacco products to cut down on smoking (dual-use approach)? [2021]

7. Use of e-cigarettes (amount and frequency)

Does the effectiveness of nicotine-containing e-cigarettes as an aid to stopping smoking vary according to the amount of nicotine they contain or the frequency of use? [2021]

8. E-cigarette flavours

Do the flavours used in nicotine-containing e-cigarettes have an impact on their effectiveness as an aid to stopping smoking, and are there any adverse effects associated with them? [2021]

9. E-cigarettes and established future smoking

Is e-cigarette use in children, young people and young adults who do not smoke associated with future established smoking? [2021]

10. Factors that may influence the use of nicotine replacement therapy and e-cigarettes

Which factors may prevent people who currently smoke tobacco from using other forms of nicotine such as NRT and nicotine-containing e-cigarettes? Does this vary according to population group, particularly among under-served groups? [2021]

11. Relapse prevention

Are NRT or nicotine-containing e-cigarettes effective for preventing relapse after a successful quit attempt? [2021]

12. Relapse prevention after enforced, temporary quit

How can people who have recently stopped or temporarily abstained from smoking in a smokefree inpatient or treatment environment be best supported after discharge to prevent relapse or to stop permanently? [2021]

13. Carbon monoxide monitoring

What is the validity of different thresholds of carbon monoxide in exhaled breath as markers of quitting, based on diagnostic review and modelling? [2018]

14. Allen Carr’s Easyway

For adults who want to stop smoking, what is the effectiveness and cost effectiveness of Allen Carr’s Easyway programme delivered in formats other than in-person group seminars (for example online or using the self-help book) compared with other methods of smoking cessation? [2022]

For specific groups who are at risk of health inequalities, for example pregnant women, people from lower socioeconomic backgrounds or people who do not speak English well:

• What is the differential effectiveness and cost-effectiveness of Allen Carr’s Easyway (including the in-person group seminar and other formats)?
• What strategies or interventions are effective in minimising those differences? [2022]

Why the committee made the recommendations

The committee wanted to discourage e-cigarette use among young people and young adults who do not smoke because evidence shows that use of e-cigarettes is linked with a higher chance of ever smoking later in life. The committee members agreed that ideas about smoking and what is normal can start from a young age so the recommendation should also apply to this age group.

The committee agreed that school-based interventions could help to discourage e-cigarette use among those who do not smoke.

The committee noted the need to not inadvertently make e-cigarettes desirable. They also emphasised that e-cigarettes should not be confused with tobacco products, so talking about them separately is important.

The committee agreed that more evidence is needed about whether e-cigarette use is linked with habitual smoking (rather than experimental smoking) in the future, the factors that determine this link, and the levels of e-cigarette use in people under 25 (see the recommendation for research on e-cigarettes and established future smoking).

How the recommendations might affect practice

Adding information about e-cigarettes to existing curriculum-based interventions to stop people taking up smoking is a change to current practice, but it should have little resource impact.

Return to recommendations

Why the committee made the recommendations

The committee looked at a large amount of evidence assessing the relative effectiveness of several interventions, including medicinally licensed products (varenicline, bupropion and nicotine replacement therapy [NRT]) and nicotine-containing e-cigarettes. They also looked at these interventions combined with each other. Most of the interventions or combinations of interventions were delivered with behavioural support. Most evidence investigated medicinally licensed products, with fewer studies about e-cigarettes.

The evidence found that these interventions were effective, and that some were likely to be more effective than others, especially in combination with behavioural support. The committee also agreed with the evidence that a combination of short- and long-acting NRT was effective as well.

Based on the evidence of relative effectiveness and their expertise, the committee agreed that several individual products, as well as short-acting and long-acting NRT in combination, were likely to lead to people successfully stopping smoking when used alongside behavioural support. The committee agreed that people should first be told about all the available options so they can make their own choice. If people do want more information about which options are likely to work best, it is important that people providing stop-smoking support or advice can make this clear. The committee discussed very brief advice and using opportunities to tell people who smoke about the range of interventions available, along with having longer discussions about these options and providing more detailed advice. They agreed these align well with the principles of NHS England’s making every contact count and NICE’s making every contact count resources.

The committee looked at the evidence for Allen Carr’s Easyway to stop smoking in-person group seminars. This is an approach that uses cognitive behavioural therapy and relaxation methods without pharmacotherapy. It also includes a final ritual cigarette at the end of the seminar, regular follow-ups and optional shorter follow-up sessions.

The evidence considered by the committee compared Allen Carr’s Easyway in-person group seminar with 1-to-1 support provided by an NHS stop smoking service (which includes behavioural support and the use of medicinally licensed products) and with a remote stop smoking service (which included behavioural support and information about how to access medicinally licensed products). The committee agreed the evidence showed it was as good as other methods such as 1-to-1 support provided by local stop-smoking services, but there was not enough evidence to position Allen Carr’s Easyway in-person group seminar within the hierarchy of effectiveness of interventions in recommendations 1.12.7 or 1.12.8.

The committee noted that evidence suggests Allen Carr’s Easyway in-person group seminar is cost effective and represents good value for money from an NHS and public sector perspective. They agreed that making it available through the NHS and local authorities alongside other interventions would broaden people’s choice, and that the more choice people have the more likely they are to find the right intervention for them. They also agreed that some people are reluctant to use pharmacotherapy, and Allen Carr’s Easyway would potentially increase the number of people attempting to stop smoking by offering an alternative to interventions that include pharmacotherapy.

The committee discussed various ways of providing the seminar, including online, but noted that the evidence they saw was only for the in-person group seminar (although in 1 study an online follow up was offered). Therefore they were unable to generalise from this evidence to formats other than the in-person group seminar.

The committee discussed the funding of studies of the intervention. One was funded by Allen Carr’s Easyway, but the committee agreed that the methods used to conduct the study minimised any risk of bias associated with this.

The committee discussed the potential effect of Allen Carr’s Easyway on inequalities in health. They noted that the length of the seminar (4.5 to 6 hours) and any travel costs to attend the seminar might be difficult for some people, and that people who are housebound would not be able to attend an in-person group seminar at all. They also noted that the evidence did not include any analysis by age, family background, or pregnancy and so it was not clear whether its effectiveness differed in these groups. The committee were unaware whether the in-person group seminars were available in languages other than English, and agreed this was a potential barrier for some people. The evidence also showed that the quit rate was greater in people with higher education in the Allen Carr Easyway in-person group seminar arm. The committee discussed that commissioners would need to know and understand the needs of their local populations to be able to commission Allen Carr’s Easyway in a way that would maximise access and use of the service.

The committee agreed that more research on the effects of Allen Carr’s Easyway in different population groups, and on the effectiveness of other ways to deliver the programme (for example the online and book versions) would be useful (see the recommendations for research on Allen Carr’s Easyway).

The committee decided not to recommend some combinations of interventions even though they were as effective as individual options. This was because, based on their experience, they had concerns over adherence rates, the difficulty of obtaining prescriptions for multiple interventions at once and a lack of information on contraindications that made these combinations less feasible than other options.

In most of the evidence, the stop-smoking product (medicinally licensed products or nicotine-containing e-cigarettes) was combined with some form of behavioural support. This meant that the results of the evidence depended on behavioural support being given alongside. The committee agreed that people providing stop-smoking support should offer behavioural support alongside any nicotine-containing products the person is using, irrespective of whether they are providing the product. This is to give people a better chance of stopping smoking. They also agreed that offering behavioural support to people using nicotine-containing e-cigarettes would increase their chances of stopping smoking.

In addition, the committee recognised the need for more evidence about what factors may prevent those who smoke from using other forms of nicotine, particularly among population groups with higher smoking prevalence. (See the recommendation for research on factors that may influence the use of nicotine replacement therapy and e-cigarettes.)

How the recommendations might affect practice

Conversations guided by each person’s preference are good practice and should already be taking place. However, extra time may be needed for people providing stop-smoking support or advice to discuss the intervention options with people who want to stop smoking, especially for the additional advice on e-cigarettes. If these recommendations lead people to quit successfully with fewer unsuccessful attempts, this may mean fewer appointments per person.

Commissioning Allen Carr’s Easyway in-person group seminar through the NHS or local authority would have resource implications for stop smoking services. But the intervention is cost effective and although the initial cost was higher than the comparator (Quit.ie or local stop smoking services group) this would be quickly offset (within 5 to 7 years) by the reduction in comorbidities and associated healthcare costs. The committee were also advised that the NHS or local authority is likely to be able to negotiate a discount for the intervention if enough people take up the offer.

The committee noted that some people living in rural areas may need help with travel costs if they need to travel long distances to attend the in-person seminar.

Return to recommendations

Why the committee made the recommendations

Evidence showed that nicotine-containing e-cigarettes can help people to stop smoking and are of similar effectiveness to other cessation options such as varenicline or long-acting and short-acting NRT.

How the recommendations might affect practice

Extra time may be needed to discuss e-cigarettes with people who are interested in using them. If these recommendations lead to more successful quit attempts, this may mean fewer appointments per person and substantial savings in downstream costs associated with smoking.

Return to recommendations

Why the committee made the recommendation

The committee agreed the importance of stop-smoking support being available to all, and that people with mental health conditions should not be treated differently in this. However, because those with mental health conditions have a higher prevalence of smoking, and are less likely to access standard smoking cessation services and have lower quit rates, it is important to look at whether additional support could be appropriate.

There was a small amount of evidence about tailored smoking cessation interventions for people with mental health conditions. The evidence of effectiveness identified was in populations with severe mental health conditions such as bipolar disorder, schizophrenia or post-traumatic stress disorder. However, the committee noted there was a lack of consensus of what constitutes a severe mental health condition. They heard from experts that people with other mental health conditions may need additional support as well. This applies both at an individual level and, for those in mental health settings, at a system level. The committee agreed that additional support should be offered to people with severe mental health conditions, and although it might be considered for other people with mental health conditions, there was insufficient evidence to make a wider recommendation. The committee noted that the recommended additional support would fit with current stop-smoking provision. Furthermore, the committee identified this as an important research gap that needs to be addressed to reduce health inequalities (see the recommendation for research on support for people with mental health conditions to stop smoking).

How the recommendation might affect practice

This potential additional support may need extra time and additional appointments. If these recommendations lead to more successful quit attempts, this may mean fewer appointments per person and substantial savings in downstream costs associated with smoking.

Return to recommendations

Why the committee made the recommendation for research

No evidence was found on the use of e-cigarettes specifically for harm reduction for people who do not want, or are not ready, to stop smoking in one go. So, the committee chose not to make recommendations on using e-cigarettes for harm reduction. They did discuss that e-cigarettes may be used in this way and that there may be substantial dual use; that is, when someone is both smoking and using e-cigarettes.

The committee agreed that more information is needed about the use of e-cigarettes for those who may wish to reduce the amount they smoke.

Return to the recommendation for research

Why the committee made the recommendations

The committee agreed that strategies to avoid relapsing are an important part of stop-smoking advice and support, and are likely to be most effective when introduced early in the process and regularly revisited.

Evidence about NRT for preventing relapse was mixed. Although there was evidence that they may be effective in people who had recently quit, using a single type of fast-acting NRT did not reduce relapse with any certainty when people had stopped smoking for longer. The committee discussed this evidence and noted that in their experience, using NRT for longer can stop people relapsing to smoking, particularly if more than 1 type of NRT is used (usually combining patches with a fast-acting form of NRT). They discussed that only offering NRT for 12 weeks could cause people to relapse.

Evidence showed that if people who have used varenicline and bupropion to stop smoking continue taking it for longer, this improves their chances of staying stopped. This included people diagnosed with serious mental illness. There were a small number of studies and they investigated different groups of people and used varenicline in different ways, so the committee had some uncertainty about the evidence.

The committee reflected on the mixed findings from the evidence. They agreed that, because preventing relapse is so important for people who have been able to stop smoking, offering longer-term pharmacotherapy to help prevent relapse was reasonable. The committee noted that bupropion was not licensed for relapse prevention. The studies that evaluated bupropion for this indication had different dosing regimens, so the committee did not specify what dose or duration of bupropion was most effective for preventing relapse.

The committee recognised the need for more evidence about which nicotine-containing products or combination of products are best at preventing relapse after a successful quit attempt (see the recommendations for research on relapse prevention and relapse prevention after enforced, temporary quit).

How the recommendations might affect practice

Stop-smoking advisers can use existing appointments to provide information about preventing relapse to people who want to stop smoking, so this is not expected to have a resource impact, though there may costs associated with prescribing additional pharmacotherapies.

Return to recommendations

Why the committee made the recommendations

The committee discussed that it is important to review any stop-smoking or harm-reduction approach taken so that any problems can be addressed. They agreed that it can take someone multiple attempts to stop smoking for good. Encouraging people who have relapsed to smoking and talking to them about trying again may mean that they stay in touch with the service and are more likely to stop smoking in the long term.

How the recommendations might affect practice

Stop-smoking advisers can use existing appointments to discuss with people the approach they are taking and future attempts to stop or reduce harm from smoking, so this is not expected to have a resource impact.

Return to recommendations

Why the committee made the recommendations

Stopping smoking in pregnancy is important for the health of both the woman and her baby.

Existing recommended practice, based on NICE’s previous guideline on stopping smoking in pregnancy and after childbirth, is to offer opt-out provision for pregnant women. The evidence about opt-out referral systems was mixed, but the most recent evidence showed that it resulted in higher self-reported quit rates and more engagement with stop-smoking support.

Most current evidence uses carbon monoxide levels of 4 parts per million (ppm) as the cut-off for referral. Based on this and their expertise, the committee recommended that a carbon monoxide reading of 4 ppm or above would be an appropriate level to automatically refer women for stop-smoking support. This also aligns with the NHS Saving Babies’ Lives Care Bundle.

The evidence about women’s views on opt-out referral showed that giving women information on carbon monoxide testing and the automatic referral was an important factor in whether they accepted the referral and took up the support. The committee discussed whether there was a specific need for a recommendation on giving information, because all clinical treatment pathways should ensure that people are fully informed and take an active part in their care. They agreed that a recommendation would be helpful in this case, because they considered opt-out treatment is not common in most areas of care.

During development of this guideline, carbon monoxide monitoring was not being used because of COVID-19 practice changes. The committee acknowledged that during the COVID-19 pandemic referral decisions may need to be made without using carbon monoxide monitoring.

How the recommendations might affect practice

The recommendations reflect current widespread practice and so should have little resource impact.

Return to recommendations

Why the committee made the recommendations

NICE’s 2010 guideline on stopping smoking in pregnancy and after childbirth (replaced by this guideline) recommended nicotine replacement therapy (NRT) for pregnant women only if they are not able to stop smoking using a behavioural intervention without NRT, and once they have stopped smoking. New evidence showed that NRT may help women stop smoking in pregnancy when added to a behavioural intervention.

The committee discussed that women may stop smoking temporarily during pregnancy and relapse afterwards. There was no evidence about continuing NRT after pregnancy to prevent this but, based on their expert opinion, the committee agreed it may be useful.

Evidence showed that advice from healthcare professionals, particularly midwives, was valuable to pregnant women and contributed to their decisions about using NRT. The evidence also showed that consistent advice addressing the main concerns women tend to have about NRT during pregnancy (such as addictiveness, potential side effects and any pregnancy impacts) may help women to feel comfortable using NRT during and after pregnancy.

We found no evidence about the effectiveness or safety of using nicotine-containing e-cigarettes to help women stop smoking in pregnancy. Many of the studies in the effectiveness meta-analysis for nicotine replacement therapies were over 10 years old and most used doses of nicotine that would now be considered to be low. The committee therefore made recommendations for research to help understand what type and dose of NRT is most effective and the views and concerns of pregnant women and their healthcare professionals about using nicotine-containing e-cigarettes in pregnancy.

How the recommendations might affect practice

The change in recommendations since NICE’s previous guideline may increase prescriptions of NRT to pregnant women, and potentially increase how long it is prescribed for. If this leads to more cases of successful quitting, it will create considerable savings downstream.

Return to recommendations

Why the committee made the recommendations

Evidence showed that offering financial incentives to help pregnant women stop smoking was both effective and cost effective. Voucher incentives were acceptable to many pregnant women and healthcare providers. The committee noted that these are already being used in some areas.

The committee discussed and agreed with the evidence that ‘contingent rewards’ (given only if biochemical tests prove the woman has stopped) were more effective than guaranteed payments given whether the woman has stopped or not.

More evidence is needed to find out what value of incentive works best. Evidence from the UK showed that schemes in which around £400 could be gained in vouchers staggered over time (with reductions for each relapse made) were effective and cost effective, so the committee included this amount as a guide.

Based on the evidence and their expertise, the committee agreed that incentive schemes that include both the pregnant woman and a significant other supporter could have a better chance of success.

They also agreed that some staff may be unfamiliar with incentive schemes and would benefit from training to help deliver them.

Although the guideline recommends that vouchers should be provided only to those with an abstinence validated by a biochemical method, the committee acknowledged that during the COVID-19 pandemic carbon monoxide validation may not be being used. While this is the case, vouchers are recommended even if biochemical validation using carbon monoxide is not possible.

How the recommendations might affect practice

Incentive schemes are already used in some areas. Areas that do not already use them will need staff time to run them, and financial resources to award the vouchers. Training for people promoting and delivering the incentive schemes may need resources.

Return to recommendations

Why the committee made the recommendations

The committee looked at a large amount of evidence assessing the relative effectiveness of interventions for stopping smoking (medicinally licensed products and nicotine-containing e-cigarettes, alone or in combination). Most of the interventions or combinations of interventions were delivered with behavioural support. The committee agreed which interventions should be accessible (see the rationale and impact section for stop-smoking interventions). They agreed that the recommendation from NICE’s 2018 guideline on stop-smoking interventions and services (replaced by this guideline) to make stop-smoking interventions available through local plans and approaches to health and wellbeing was still relevant, so they drew on that to make a new recommendation.

The committee noted that not all medicinally licensed products are available in all stop-smoking services, and so local arrangements are in place to ensure that these are accessible when needed. Nicotine-containing e-cigarettes are not licensed medicines so cannot currently be provided on prescription. However, there are ways of increasing their accessibility, for example by giving evidence-based advice about them and information on where people can access them. The committee were aware that some services use vouchers or starter pack schemes.

Based on evidence and their experience of the use of NRT for preventing relapse, the committee recommended it for longer-term use (see the rationale and impact section for supporting people trying to stop smoking) and agreed this needed to be reflected in service specifications to make sure it was made available.

The committee heard from experts that smoking prevalence is high in some population groups that may not be well served by existing stop-smoking provision (such as those with mental health conditions, or those who identify as LGBT+, or those with low income). And that although these groups may be motivated to stop smoking, they may experience additional challenges to successfully stopping (see the equality impact assessment).

We did not find any evidence on how to tailor effective and cost-effective interventions to ensure that they are engaging and accessible for under-served groups, or how acceptable those interventions may be for those groups. The committee identified this as an important gap that needs to be addressed to reduce health inequalities (see the recommendation for research on stop-smoking interventions for under-served groups).

How the recommendations might affect practice

The committee noted that schemes are already in place in some areas to support starting the use of nicotine-containing e-cigarettes for stopping smoking.

NICE’s 2013 guideline on smoking harm reduction already recommended that service specifications require providers of stop-smoking support to offer long-term NRT.

Return to recommendations

Why the committee made the recommendation

The committee agreed that nicotine-containing products should be available for sale in secondary care settings to help people stop smoking and to support temporary abstinence for patients, staff and visitors because hospital grounds are covered by smokefree legislation.

How the recommendation might affect practice

Making the full range of effective options available for sale may be a change to current practice, but it is not expected to have a large impact on resources.

Return to recommendations