Recommendations on policy, commissioning and training

Guidance

1.21 Policy
1.22 Commissioning and designing services
1.23 Training

Recommendations on policy, commissioning and training

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

This guideline should be read alongside NICE's guidelines on patient experience in adult NHS services and babies, children and young people's experience of healthcare, which have guidance on giving information to people and discussing their views and preferences.

In this guideline, we use the following terms for age groups:

children: aged 5 to 11
young people: aged 12 to 17
young adults: aged 18 to 24
adults: aged 18 and over.

At the time of publication (November 2021), no nicotine-containing e-cigarettes were licensed as a medicine for stopping smoking by the Medicines and Healthcare products Regulatory Agency (MHRA) and commercially available in the UK market. All nicotine-containing e‑cigarettes in the UK that are not licensed as a medicine by the MHRA are regulated by the Tobacco and Related Products Regulations (2016), and cannot be marketed by the manufacturer for use for stopping smoking.

These recommendations are for people with responsibility for developing smokefree policy, and for commissioning and training services.

1.21 Policy

1.21.1

Develop a policy for smokefree grounds in collaboration with secondary care staff and people who use secondary care services, including services in the community, or their representatives. The policy should:

set out a clear timeframe to establish or reinstate smokefree grounds
identify the roles and responsibilities of staff
ban staff from supervising or helping people to take smoking breaks
identify the resources needed to support the policy
ban the sale of tobacco products
be periodically reviewed and updated, in line with all other organisational policies. [2013]

1.21.2

Ensure smokefree implementation plans include:

support for staff and people who use secondary care services to stop smoking completely or temporarily
training for staff (see the section on training for healthcare staff)
removing shelters or other designated outdoor smoking areas
staff, contractor and volunteer contracts that do not allow smoking during work hours or when recognisable as an employee (for example, when in uniform, wearing identification, or handling hospital business)
how secondary care staff can work with people who use services and carers to protect themselves from tobacco smoke when they visit people's homes. (In accordance with smokefree legislation, employers must take action to reduce the risk to the health and safety of their employees from secondhand smoke to as low a level as is reasonably practicable.) [2013]

1.21.3

Ensure policies, procedures and resources are in place to:

help comply with, and resolve immediately, any breaches of smokefree policies, including a process for staff to report incidents
support staff to encourage others to comply with the smokefree policy
work with people who use services, carers, visitors and staff to overcome any problems that may result from smoking restrictions (supported by 'personal care plans' as covered in the section on information on stopping smoking for those using acute, maternity and mental health services). [2013]

1.21.4

Ensure all staff are aware of the smokefree policy and comply with it. [2013]

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]

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]

1.22 Commissioning and designing services

These recommendations are for directors and senior managers in settings where stop-smoking support is needed, and commissioners, providers and managers of stop-smoking support.

1.22.1

Use integrated care systems plans, health and wellbeing strategies, and other relevant local strategies and plans to make the range of interventions in the section on stop-smoking interventions accessible to adults who smoke. [2021]

1.22.2

Ensure service specifications require providers of stop-smoking support to offer nicotine replacement therapy (NRT) for as long as needed to help prevent a relapse to smoking. [2021]

1.22.3

Use the government's local tobacco control profiles to estimate smoking prevalence among the local population. [2018]

1.22.4

Prioritise groups at high risk of tobacco-related harm. These may include:

people with mental health conditions (for example, see NICE's guideline on depression in adults)
people who misuse substances (for example, see NICE's guideline on coexisting severe mental illness and substance misuse: community health and social care services)
people with health conditions caused or made worse by smoking (for example, see NICE's guidelines on cardiovascular disease: identifying and supporting people most at risk of dying early, type 1 diabetes in adults, asthma and chronic obstructive pulmonary disease)
people with a smoking-related illness (see NICE's guideline on lung cancer)
populations with a high prevalence of smoking-related morbidity or a particularly high susceptibility to harm
communities or groups with particularly high smoking prevalence (such as manual workers, travellers and LGBT+ people)
people with a low socioeconomic status
pregnant women who smoke. [2018]

For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on commissioning and designing services.

Full details of the evidence and the committee's discussion are in:

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]

For a short explanation of why the committee made the 2021 recommendation and how it might affect practice, see the rationale and impact section on stop-smoking support in secondary care.

Full details of the evidence and the committee's discussion are in evidence review K: cessation and harm-reduction treatments.

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]

1.23 Training

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]

Training on stopping smoking

Healthcare staff

1.23.2

Train all frontline healthcare staff to offer very brief advice on how to stop smoking in accordance with the section on support to stop smoking in primary care and community settings. Also train them to make referrals, if necessary and possible, to local stop-smoking support. Frontline secondary care staff should also be trained to refer people for behavioural support. [2013, amended 2018]

1.23.3

Provide additional, specialised training on providing stop-smoking support for those working with specific groups, for example people with mental health conditions and pregnant women who smoke. [2008, amended 2018]

1.23.4

Encourage and train healthcare professionals to ask people about smoking and to advise them of the dangers of exposure to secondhand smoke. [2008, amended 2018]

People working in closed institutions

1.23.5

Ensure staff working in closed institutions recognise that some people see smoking as an integral part of their lives. Also ensure staff recognise the issues arising from being forced to stop, as opposed to doing this voluntarily. [2013]

1.23.6

Ensure staff recognise how the closed environment may restrict the techniques and coping mechanisms that people would normally use to stop smoking or reduce the amount they smoke. Provide the support needed for their circumstances. This includes prescribing or supplying medicinally licensed nicotine-containing products. [2013]

1.23.7

Ensure staff understand that if someone reduces the amount they smoke, or stops completely, this can affect psychotropic and some other medications (see the summaries of product characteristics for individual drugs in the electronic medicines compendium for further details). Ensure arrangements are in place to adjust their medication accordingly. See the section on medicine dosages for people who have stopped smoking. [2013]

1.23.8

Do not allow staff with health and social care or custodial responsibilities to smoke during working hours in locations where the people in their care are not allowed to smoke. [2013]

Midwives and others working with pregnant women

1.23.9

Ensure all midwives are trained to assess and record people's smoking status and their readiness to quit. They should also:

know about the health risks of smoking and the benefits of quitting
understand why it can be difficult to stop
know about the treatments that can help people to quit, including nicotine replacement therapy
know how to refer people who smoke to local services for treatment.

See the National Centre for Smoking Cessation and Training's (NCSCT) module on very brief advice on smoking for pregnant women. [2010, amended 2021]

1.23.10

Ensure all healthcare and other professionals who work with pregnant women are trained in the same skills to support women to stop smoking, and to the same standard, as midwives. This includes:

GPs, practice nurses
health visitors
obstetricians
paediatricians
sonographers
midwives (including young people's lead midwives)
family nurses
those working in fertility clinics, dental facilities and community pharmacies
those working in youth and teenage pregnancy services, children's centres, social services and voluntary and community organisations. [2010]

1.23.11

Ensure that all healthcare and other professionals who work with pregnant women (see recommendation 1.23.10):

understand the impact that smoking can have on a woman and her unborn child
understand the dangers of exposing a pregnant woman and her unborn child – and other children – to secondhand smoke. [2010]

1.23.12

Train all midwives who deliver intensive stop-smoking interventions (one-to-one or group support) to the same standard as stop-smoking advisers. The minimum standard for these interventions is set by the NCSCT. Also provide additional, specialised training and offer them ongoing support and training updates.

See the NCSCT's specialty module on pregnancy and the postpartum period. [2010]

1.23.13

Ensure that midwives and specialist stop-smoking advisers who work with pregnant women:

know how to ask them questions in a way that encourages them to be open about their smoking
always recommend quitting rather than cutting down
have received accredited training in the use of carbon monoxide monitors. [2010]

Healthcare staff and others who advise people how to stop using smokeless tobacco

1.23.14

Ensure training for health, dental health and allied professionals (for example, community pharmacists) covers:

the fact that smokeless tobacco may be used locally – and the need to keep abreast of statistics on local prevalence
the reasons why, and how, members of the South Asian community use smokeless tobacco (including the cultural context for its use)
the health risks associated with smokeless tobacco
the fact that some people of South Asian family origin may be less used to a preventive approach to health than the general population
the local names used for smokeless tobacco products, while emphasising the need to use the term 'smokeless tobacco' as well when talking to users about them. [2012]

1.23.15

Ensure training helps professionals to:

recognise the signs of smokeless tobacco use
know how to ask someone, in a sensitive and culturally aware manner, whether they use smokeless tobacco
provide information in a culturally sensitive way on the harm smokeless tobacco causes (this includes being able to challenge any perceived benefits – and the relative priority that users may place on these benefits)
deliver a brief intervention and refer people to tobacco cessation services if they want to quit. [2012]