This guide is part of ‘All Our Health’, a resource that helps health and care professionals prevent ill health and promote wellbeing as part of their everyday practice. It will help you:
- understand the specific activities and interventions that support a smoker to quit
- access training resources to support your learning and to further develop your skills in motivating and supporting smokers to quit
- think about the resources and services available in your area that can help people quit smoking
We also recommend important actions that managers and staff holding strategic roles can take.
View the full range of All Our Health topics.
2. Access the smoking and tobacco e-learning session
An interactive e-learning version of this topic is now available to use.
Public Health England (PHE) and Health Education England’s ‘e-Learning for Healthcare’ have developed this content to increase the confidence and skills of health and care professionals, to embed prevention in their day-to-day practice.
Completing this session will count towards your continued professional development.
3. Focus on smoking in your professional practice
Smoking is uniquely harmful, causing damage not only to smokers themselves but also to the people around them. Smoking is one of the main causes of health inequalities in England, with the harm concentrated in more disadvantaged communities and groups.
Despite a continued decline in smoking prevalence, 14.4% of adults in England still smoke – over 6 million people in 2018.
Smoking is the leading cause of preventable illness and premature death, killing 78,000 people in England each year. US data indicate that for every death caused by smoking, at least 30 smokers are living with a serious smoking-related illness. In England, in 2017 to 2018, there were an estimated 489,300 smoking-related admissions to hospital, equating to over 1,300 each day. One in 4 patients in hospital beds are smokers. Smokers also see their GP 35% more than non-smokers.
Stopping smoking at any time has considerable health benefits. For people using secondary care services, there are other advantages. These include shorter hospital stays, lower drug doses, fewer complications, higher survival rates, better wound healing, decreased infections and fewer re-admissions after surgery.
Smoking is not a lifestyle choice but a chronic relapsing condition needing treatment. This is recognised by the government’s commitment for the NHS in England to become smokefree. Supporting smokers in contact with the healthcare system to quit is a prevention priority in the NHS Long Term Plan and every health and care professional has a role to play.
3.1 Facts about smoking
Smoking harms nearly every organ of the body. It causes lung cancer, respiratory disease and cardiovascular disease as well as many cancers in other organs including lip, mouth, throat, bladder, kidney, stomach, liver and cervix. Smoking reduces fertility and significantly raises the risk of developing type 2 diabetes, eye disease and dementia.
Secondhand smoke is dangerous for anyone exposed to it, but children are especially vulnerable due to breathing more rapidly and having less developed airways, lungs and immune systems.
Smoking is the single most important modifiable risk factor in pregnancy. Smoking is associated with a range of poor pregnancy outcomes including miscarriage, stillbirth, premature birth, neonatal complications, low birth weight and sudden infant death syndrome. Over 1 in 10 babies in England are born to a mother who smoked throughout her pregnancy.
Around 1 in 3 cigarettes in Britain is smoked by someone with a mental health condition. Among adults with a serious mental illness, 40.5% smoke. High smoking rates among people with mental health conditions are the single largest contributor to their 10 to 20-year reduced life expectancy.
People with a mental health condition are just as likely to want to stop smoking as those without, but they are more likely to be addicted to smoking and more likely to think it will be difficult to quit.
3.2 Quitting smoking: the importance of support
Around 3 out of 5 smokers say they want to quit, with 1 out of 5 intending to do so within 3 months. Prompts by healthcare professionals are the second most common reason for someone making a quit attempt. Currently, around half of all smokers in England try to quit unaided using willpower alone, despite this being the least effective method. Getting support can greatly increase a person’s chances of quitting successfully.
PHE has published Stop smoking options: guidance for conversations with patients to support conversations between clinicians and people who smoke on what method to choose to help them quit.
3.3 Local stop smoking services
Expert support from a local stop smoking service gives smokers the best chance of quitting for good. Depending on the area, services can be based in a range of settings including integrated lifestyle services, community pharmacies and GP surgeries. Stop smoking services are free and offer a choice of one-to-one or group behavioural support from a trained stop smoking advisor together with pharmacotherapy.
3.4 E-cigarettes / vapes
E-cigarettes, also known as vapes, are the most commonly used quit aid among smokers in England and there is growing evidence of their effectiveness. A major UK clinical trial found e-cigarettes, when combined with face-to-face behavioural support, to be twice as effective for quitting smoking as other nicotine replacement products such as patches or gum.
Leading health and public health organisations including the Royal College of General Practitioners (RCGP), British Medical Association (BMA), Cancer Research UK and the US National Academies of Sciences, Engineering and Medicine agree that although not risk-free, e-cigarettes are far less harmful than smoking. Based on the currently available evidence, PHE and the Royal College of Physicians estimate the risk reduction to be at least 95%.
National Institute for Health and Care Excellence (NICE) guideline 92 recommends that health and social care professionals provide advice to smokers who are using, or interested in using, an e-cigarette for quitting.
3.5 The evidence on nicotine
The evidence shows that while nicotine is the addictive substance in cigarettes, it is relatively safe. In fact, almost all the harm from smoking comes from the thousands of other chemicals in tobacco smoke, many of which are toxic. Despite this:
- 4 in 10 smokers and ex-smokers incorrectly think nicotine causes most of the smoking-related cancer
- only just over half of adults think that nicotine replacement therapy is any less harmful than smoking
Advising smokers on the relative risks of nicotine-containing products compared to smoked tobacco is an integral part of supporting them to quit.
4. Core principles for health and care professionals
Every front-line health and care professional should:
- discuss smoking with their patients
- routinely offer all smokers advice and support to quit smoking as part of routine care
- deliver evidence-based interventions in accordance with NICE guidance
5. Taking action
5.1 If you’re a front-line health and care professional
Smokers expect healthcare professionals to ask about their smoking. As a healthcare professional, you are best placed to motivate and support smokers on their quit journey.
All healthcare professionals should identify and refer smokers using the method known as Very Brief Advice (VBA) which has 3 components – ‘Ask, Advise and Act’:
- Ask and record smoking status: is the patient a smoker, ex-smoker or non-smoker?
- Advise on the best way of quitting: the best way of stopping smoking is with a combination of stop smoking aids and specialist support.
- Act on patient response: build confidence, give information, refer and prescribe.
Undertake free online training provided by the National Centre for Smoking Cessation and Training (NCSCT), and find out what local training is available and how you can access it.
Find out about the quitting support available in your area and make sure that you know how to refer smokers for specialist support.
Different approaches suit different people so if the first thing a smoker tries does not help, they should try another way. We’ve published guidance to support you in your conversations with patients on what method to choose.
Working with pregnant women
If you work with pregnant women make sure carbon monoxide (CO) monitoring is in place for all pregnant women, with those having elevated levels referred for specialist stop smoking support. Also, make sure all members of the midwifery team are trained to use the CO monitor and have brief meaningful conversations about the harms of smoking and know about the quitting support available.
Robust and effective pathways into specialist support should be in place, with feedback to the referring midwife.
Working with people who have mental health problems
If you work with people who have mental health problems, make sure you treat tobacco dependence as part of routine clinical care.
People with mental health problems want to quit smoking as much as other smokers do and have the same right to be offered effective stop smoking support.
This includes providing access to a full range of stop smoking medicines and behavioural support to assist them in quitting for good or abstaining temporarily while in a smokefree inpatient setting. You should encourage the use of e-cigarettes as one of the range of options available to support quitting or reducing harm.
5.2 If you’re a team leader or manager
As a team leader or manager, you should:
- make sure the teams you lead are aware of latest guidance and interventions on supporting people to stop smoking
- provide learning and development opportunities for team members on supporting smokers to quit and how they can provide VBA
- make sure there are clear local referral and care pathways to stop smoking support
- provide feedback to local commissioners and providers where services are working well and where there are problems accessing support for smokers who want to quit
5.3 If you’re a senior or strategic leader
As a senior or strategic leader, you should:
- make sure there is a shared understanding of the local level of demand and need, based on a range of local and national data across a range of public services
- include stop smoking support in health and wellbeing boards’ joint strategic needs assessments (JSNA)
- commission evidenced-based stop smoking support which reflects strategic priorities and the needs of the local population
- consider whether your local tobacco control network would benefit from undertaking an evidenced-based CLeaR self-assessment (and peer-assessment) of their systems and services
- seek opportunities to work together on tobacco with local partners including primary care networks, secondary care providers, clinical commissioning groups, local authorities, sustainability and transformation partnerships and integrated care systems
- work to promote stop smoking support prominently in all commissioned healthcare services
- make sure to include the screening and brief advice for alcohol and tobacco use in inpatient settings CQUIN scheme in the NHS Standard Contract
6. Understanding local needs
There are 3 indicators in the Public Health Outcomes Framework which relate to smoking:
- Smoking status at time of delivery (indicator 2.03).
- Smoking prevalence at age 15 (indicator 2.09).
- Smoking prevalence in adults (18+) (current smokers) based on Annual Population Survey (APS) data (indicator 2.14).
The Local Tobacco Control Profiles for England provides a snapshot of the extent of tobacco use, tobacco-related harm, and measures being taken to reduce this harm at a local level. We designed the profiles to help local government and health services assess the effect of tobacco use on their local populations. Examples of indicators include:
- smoking prevalence in adults in routine and manual occupations (18 to 64) – current smokers – APS data
- smoking prevalence in adults (18 to 64) – socio-economic gap in current smokers – APS data
- smoking prevalence in adults (18+) with serious mental illness
- smoking attributable mortality
- smoking attributable deaths from heart disease
- smoking attributable deaths from stroke
- smoking attributable hospital admissions
- potential years of life lost due to smoking-related illness
- smokers that have successfully quit at 4 weeks
- smokers setting a quit date
7. Measuring local impact
As a healthcare professional, there is a range of reasons why it makes sense to measure your impact and show the value of your contribution. This could be about sharing what has worked well to benefit your colleagues and local people, or to help you with your professional development.
7.1 Everyday Interactions toolkit
The Royal Society for Public Health (RSPH) toolkit provides a quick, straightforward and easy way for healthcare professionals to record and measure their public health impact in a uniform and comparable way.
They also recommend the smoking and tobacco impact pathway for healthcare professionals to record and measure actions undertaken as part of routine care.
7.2 CLeaR improvement model
CLeaR is a continuous improvement model that supports local action to reduce the use of tobacco. The model is designed for use by local authorities, tobacco alliances and NHS partners. The CLeaR model offers:
- A free-to-access self-assessment tool that can assist in evaluating the effectiveness of local action addressing harm from tobacco – a major aspect of any health and wellbeing strategy.
- An opportunity to bring local partners together to discuss the range of local tobacco control efforts and reinforce efforts and priorities.
- A voluntary peer assessment process, which provides independent challenge to self-assessments and access to a recognised quality mark.
- A chance to benchmark work on tobacco over time and against others.
A series of deep-dive self-assessment tools follow the same design as the generic CLeaR improvement tool but focus on specific issues. They cover:
- smoking in pregnancy
- smoking in acute settings
- smoking in mental health settings
- tackling illicit tobacco
8. Further reading, resources and good practice examples
8.1 Advice for patients and the public
The NHS Smokefree website also offers a range of support tools and information on quitting smoking, along with how to access free, proven support to help you quit.
The NHS Live Well website also provides information, advice and support, with details of how to find local support to quit.
Specific information, advice and support for smokers who are pregnant is provided by NHS Smokefree and Tommy’s.https://www.youtube-nocookie.com/embed/qljBzXmTqjE?enablejsapi=1&origin=https%3A%2F%2Fwww.gov.uk&rel=0&disablekb=1&modestbranding=1&channel&widgetid=1
8.2 Professional resources and tools
Health matters: stopping smoking – what works? focuses on the range of smoking quitting routes that are available and the evidence for their effectiveness. Two-thirds of smokers say they want to quit, however, most try to do so unaided, which is the least effective method.
Stop smoking options: guidance for conversations with patients supports healthcare professionals in their conversations with patients on the different options available for stopping smoking and their effectiveness.
The NCSCT has produced a series of practical briefings for healthcare professionals covering many of the main issues that arise when giving advice to smokers.
The BMA provides some answers to common questions on e-cigarettes to support doctors when discussing their use with patients. See What should doctors say? on the BMA website.https://www.youtube-nocookie.com/embed/AgkB1iZOrdI?enablejsapi=1&origin=https%3A%2F%2Fwww.gov.uk&rel=0&disablekb=1&modestbranding=1&channel&widgetid=2
Cancer Research UK’s E-cigarette hub provides information and access to resources for health professionals.
PHE publishes annual independent evidence reports on e-cigarettes, accessible via this collection page.
The Royal College of Physicians report Hiding in plain sight: treating tobacco dependency in the NHS addresses the harms and costs arising from smoking in the patients whom clinicians see every day, and argues for a new approach to treating their addiction.
The Smoking in Pregnancy Challenge Group has developed resources to support health professionals working to reduce smoking in pregnancy.
Smoking Cessation: a briefing for midwifery staff gives expert, concise guidance on how to deliver VBA to pregnant women who smoke and how to carry out routine carbon monoxide (CO) screening with all pregnant women.
Smoking Cessation and Mental Health: A briefing for front-line staff is aimed at those who work in a mental health setting and gives expert, concise guidance on how to deliver VBA to patients who smoke.
The Mental Health and Smoking Partnership has developed a suite of resources to support health professionals working to reduce smoking among people with mental health conditions.
The Care Quality Commission Brief guide: Smokefree policies in mental health inpatient services notes that mental health care providers have a duty of care to protect the health of, and promote healthy behaviour among, people who use, or work in, their services. This includes providing effective support to stop smoking or to temporarily abstain from smoking while using or working in secondary care inpatient services.
8.3 Resources to support commissioning
The Stop Smoking Services: Models of Delivery guidance supports directors of public health and local healthcare commissioners in rapidly appraising the evidence, to enable informed decisions on the provision of local stop smoking support. CLeaR is an evidence-based improvement model that supports local action to reduce the use of tobacco. The model is designed for use by local authorities, tobacco alliances and NHS partners.
The tobacco control commissioning support (JSNA) pack supports local needs assessment processes and commissioning of tobacco control interventions. It also introduces a model from behaviour change theory, to support commissioners to do a systematic analysis of their available commissioning options.
The ASH Local Toolkit is a set of materials for local public health professionals involved in tobacco control. The materials are designed for use with councillors and other stakeholders to help ensure that tackling tobacco use is high on the local public health agenda.
Local health and care planning: menu of preventative interventions outlines public health interventions that can improve the health of the population and reduce health and care service demand.
8.4 NICE guidance and quality standards
NICE treatment pathways on smoking is an interactive flowchart that covers interventions and strategies to prevent children and young people from taking up smoking and to help everyone who already smokes to stop.
Stop smoking interventions and services (NG92) covers stop smoking interventions and services delivered in primary care and community settings for everyone over the age of 12. It aims to ensure that everyone who smokes is advised and encouraged to stop and given the support they need. It emphasises the importance of targeting vulnerable groups who find smoking cessation hard or who smoke a lot. The guidance includes recommendations on the advice that health and social care professionals should provide to smokers on using an e-cigarette for quitting.
Smoking: supporting people to stop (QS43) covers support for people to stop smoking. It includes referral to stop smoking services and treatments to help people to stop smoking. It describes high-quality care in priority areas for improvement.
Smoking: harm reduction (PH45) covers reducing harm from smoking. It aims to help people, particularly those who are highly dependent on nicotine, who:
- may not be able (or do not want) to stop smoking in one step
- may want to stop smoking, without necessarily giving up nicotine
- may not be ready to stop smoking but want to reduce the amount they smoke
Smoking: harm reduction (QS92) covers ways of reducing harm from smoking. It includes advice on supporting people who do not want to give up smoking in one step. It describes high-quality care in priority areas for improvement.
Smoking: stopping in pregnancy and after childbirth (PH26) covers support to help women stop smoking during pregnancy and in the first year after childbirth. It includes identifying women who need help to quit, referring them to stop smoking services and providing intensive and ongoing support to help them stop. The guideline also advises how to tailor services for women from disadvantaged groups in which smoking rates are high.
Smoking: acute, maternity and mental health services (PH48) covers helping people to stop smoking in acute, maternity and mental health services. It promotes smokefree policies and services and recommends effective ways to help people stop smoking or to abstain from smoking while using or working in secondary care settings.
Smoking: workplace interventions (PH5) covers how employers can encourage and support employees to stop smoking. It aims to reduce the number of people who smoke or are exposed to second-hand smoke and the rate of diseases and conditions caused by smoking.
Smokeless tobacco: South Asian communities (PH39) covers people living in England with ancestral links to Bangladesh, India, Nepal, Pakistan or Sri Lanka who use traditional South Asian varieties of smokeless tobacco. The aim is to help them stop using tobacco that is placed in the mouth or nose (but not burned).
Smoking: reducing and preventing tobacco use (QS82) covers reducing tobacco use, including interventions to discourage people from taking up smoking, tobacco control strategies and smokefree policies.
8.5 Online training resources
The NCSCT was established to support the delivery of smoking cessation interventions provided by local stop smoking services, support the NHS and local authorities to deliver effective evidence-based tobacco control programmes, and deliver training and assessment programmes to stop smoking practitioners and other health care professionals.
The NCSCT provides a range of free online training materials including:
- VBA training module
- VBA on smoking for pregnant women
- Stop Smoking Practitioner training and certification
- smoking in pregnancy specialty module
- secondhand smoke training module
- mental health specialty module
- e-cigarettes: a guide for healthcare professionals
- stop smoking medications
Health Education England provides programmes on supporting smokers to quit via the e-Learning for Healthcare programme, including:
- Smoking in pregnancy programme supports members of the midwifery team provide VBA on smoking to their patients, including carbon monoxide (CO) monitoring.
- Alcohol and tobacco brief interventions provides healthcare professionals with the minimum level of knowledge and skill needed to confidently and effectively identify risk and provide brief advice to patients who smoke or who are drinking at a level that could be harming them. It supports staff training to meet requirements of the screening and brief advice for alcohol and tobacco use in inpatient settings CQUIN scheme.
8.6 Good practice examples
The Greater Manchester tobacco control plan ‘Making Smoking History’ supports a comprehensive, whole system approach to tackling tobacco. The CURE project is an integral part of delivering this plan and is included in its strategy, delivering a service and pathway for patients admitted to acute care, taking advantage of a unique teachable moment.
Sheffield Health and Social Care NHS Foundation Trust is reducing harm from tobacco to service users and staff, addressing complex implementation challenges. You can read about the approach in our published case study.
Local Maternity Systems
The Smoking in Pregnancy Challenge Group has produced a resource for Local Maternity Systems (LMS) which presents three case studies from LMS that are working together and proactively across local areas to reduce rates of smoking in pregnancy. You can download the case studies from the Smokefree Action Coalition website.