Quality statement 4: Harm-reduction approach | Tobacco: treating dependence | Quality standards

Quality statement

People who do not want, or are not ready, to stop using tobacco in one go receive support to adopt a harm-reduction approach. [2015, updated 2022]

Rationale

Stopping using tobacco reduces the risks of developing tobacco-related illnesses or worsening conditions affected by its use, however some people may not want, or be ready, to stop in one go. It is important that they are encouraged and supported to adopt a harm-reduction approach, such as smoking less or using less smokeless tobacco or stopping temporarily. People who reduce their tobacco use are more likely to stop in the future. Harm-reduction approaches should not detract from tobacco cessation approaches, but should support and extend the reach and impact of tobacco cessation support.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly. Some localities may want to focus on equality of care depending on local needs, for example, by assessing care for particular socioeconomic or ethnic groups.

Process

The following process measure denominator uses a key point of contact for measurement purposes only.

Proportion of people given advice on stopping smoking or using smokeless tobacco at a key point of contact who do not want, or are not ready, to stop in one go who receive support to adopt a harm-reduction approach.

Numerator – the number in the denominator who receive support to adopt a harm-reduction approach.

Denominator – the number of people given advice on stopping smoking or using smokeless tobacco at a key point of contact who do not want, or are not ready, to stop in one go.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

What the quality statement means for different audiences

Service providers (such as primary care services, secondary care services and stop-smoking services) ensure that harm-reduction approaches are available for people who do not want, or are not ready, to stop smoking in one go. They ensure the availability of self-help materials that include advice on choosing a harm-reduction approach and details of where to find more help and support. They ensure that medicinally licensed nicotine-containing products are available for people who smoke, and there are referral pathways to local and specialist tobacco cessation services for people who smoke or use smokeless tobacco.

Healthcare professionals (such as GPs, providers of stop-smoking support and tobacco dependence specialists) are aware of harm-reduction approaches. They discuss the approach that might be most suitable for the person, based on their behaviour, previous attempts to stop, health and social circumstances, and preferences. They provide advice on the use of medicinally licensed nicotine-containing products and, if possible, prescribe or supply them to people who smoke. They are aware of referral pathways to local and specialist tobacco cessation services for people who smoke or use smokeless tobacco.

Commissioners (such as local authorities and integrated care systems) ensure they commission services that provide support for people to adopt a harm-reduction approach. They commission services that offer medicinally licensed nicotine-containing products on a long-term basis to people who smoke. If local needs assessment shows that it is necessary, a range of services should be commissioned to help South Asian people who use smokeless tobacco. This can be within existing stop-smoking support, part of services offered within a range of healthcare and community settings, or a stand-alone service tailored to local needs. They should ensure that harm-reduction approaches support and extend the reach and impact of tobacco cessation support.

People who do not want, or are not ready, to stop smoking or using smokeless tobacco in one go receive advice on reducing the number of cigarettes or amount of smokeless tobacco they use, or temporarily stopping. People who smoke are offered products that contain nicotine such as patches, gum, tablets for under the tongue, lozenges or sprays, or are told where they can get them. People who use smokeless tobacco are offered referral to local specialist tobacco cessation services.

Source guidance

Tobacco: preventing uptake, promoting quitting and treating dependence. NICE guideline NG209 (2021, updated 2022), recommendations 1.15.2 to 1.15.7 and 1.22.7 to 1.22.9

Definitions of terms used in this quality statement

Tobacco

Includes smoked tobacco, such as cigarettes and shisha, and smokeless tobacco.

Smokeless tobacco is any product containing tobacco that is placed in the mouth or nose and not burned. It is typically used in England by people of South Asian family origin. It does not include products that are sucked, like 'snus' or similar oral snuff products (as defined in the European Union 2014 Tobacco Products Directive). The types used vary across the country, but they can be divided into 3 main categories based on their ingredients:

Tobacco with or without flavourants: misri India tobacco (powdered) and qimam (kiman).
Tobacco with various alkaline modifiers: khaini, naswar (niswar, nass) and gul.
Tobacco with slaked lime as an alkaline modifier and areca nut: gutkha, zarda, mawa, manipuri and betel quid (with tobacco).

[Adapted from NICE's guideline on tobacco, terms used in this guideline (smokeless tobacco), final scope (2018) and expert opinion]

Harm-reduction approach

Approaches that aim to reduce harm to people who smoke by smoking less or abstaining temporarily. The following approaches should be discussed to determine which might be most suitable.

Cutting down before stopping:

with the help of 1 or more medicinally licensed nicotine-containing products (the products may be used as long as needed to prevent relapse to previous levels of tobacco use)
without using medicinally licensed nicotine-containing products.

Reduction:

with the help of 1 or more medicinally licensed nicotine-containing products (the products may be used as long as needed to prevent relapse to previous levels of tobacco use)
without using medicinally licensed nicotine-containing products.

Temporarily stopping:

with the help of 1 or more medicinally licensed nicotine-containing products
without using medicinally licensed nicotine-containing products.

People who use smokeless tobacco should be referred to local specialist tobacco cessation services. [Adapted from NICE's guideline on tobacco, box 1, recommendation 1.16.3 and expert opinion]

Key points of contact

Such as:

a consultation with a newly registered patient
a consultation about a condition related to smoking or use of smokeless tobacco
a dental appointment
an NHS health check
an annual review
a preoperative appointment
during an inpatient episode
an outpatient appointment
at presentation at an emergency department
at first contact with social care services
as part of a Care Act assessment
at presentation after not being in regular contact with a health and social care professional.

[Expert opinion]

Equality and diversity considerations

People should be provided with advice that they can easily understand themselves, or with support, so they can communicate effectively with healthcare services. It should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate and age appropriate. People should have access to an interpreter or advocate if needed.

For people with additional needs related to a disability, impairment or sensory loss, communication support should be provided as set out in NHS England's Accessible Information Standard or the equivalent standards for the devolved nations.