Tobacco: preventing uptake, promoting quitting and treating dependence

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

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]

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

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

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]

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

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

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]

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

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]

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]

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]

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]

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]

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

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]

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]

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]

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]

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]

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

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]

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]

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]

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

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]

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]

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]

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]

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

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

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]

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]

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]

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]

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]

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

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

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]

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

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]

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]

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

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]

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]

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]

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

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

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]

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]

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]

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

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

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]

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]

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]

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]

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]

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

Use the information gathered about smoking behaviour (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]

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]

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]

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]

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

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]

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]

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]

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

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

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]

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]

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]

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]

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]

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

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]

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]

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]

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

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]

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]

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]

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]

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]

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

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]