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Smoking: harm reduction

  • This Guidelines summary includes recommendations 2–8. Please refer to the full guideline for the complete list of recommendations

Harm reduction approaches covered by the guidance

  • Stopping smoking, but using one or more licensed nicotine containing products as long as needed to prevent relapse
  • Cutting down prior to stopping smoking (cutting down to quit):
    • with the help of one or more licensed nicotine-containing products (the products may be used as long as needed to prevent relapse)
    • without using licensed nicotine-containing products
  • Smoking reduction:
    • with the help of one or more licensed nicotine-containing products (the products may be used as long as needed to prevent relapse)
    • without using licensed nicotine-containing products
  • Temporary abstinence from smoking:
    • with the help of one or more licensed nicotine-containing products
    • without using licensed nicotine-containing products
  • The approaches covered by this guidance are aimed at people 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

Self-help materials

  • Provide self-help materials in a range of formats and languages, tailored to meet the needs of groups where smoking prevalence and tobacco dependency is high. For example, these may include people with a mental illness, people from lower socioeconomic groups and people from lesbian, gay and bisexual and trans-gendered groups. Also, target groups that are less likely to access services focusing on abrupt cessation
  • Self-help materials should include:
    • details about the harm-reduction approaches outlined above
    • an emphasis on the fact that stopping smoking will improve health far more than continuing to smoke, even at a reduced rate
    • advice on how to plan a schedule (see Behavioural support)
    • advice on strategies to cut down and gradually stop or reduce the amount they smoke (see Behavioural support)
    • benefits of using licensed nicotine-containing products to reduce the harm from smoking
    • type of licensed nicotine-containing products available (the MHRA website is the most up-to-date source)
    • how to use licensed nicotine-containing products effectively to manage the cravings, mood swings and other effects of nicotine dependency and to prevent relapse
    • where licensed nicotine-containing products can be purchased and who is able to supply or prescribe them
    • where to get further help and support
    • use social media websites as a means of promoting self-help materials

Choosing a harm-reduction approach

  • Identify people who smoke and advise them to stop smoking in one step as the best approach. See NICE guidance on smoking cessation services and brief interventions and referral for smoking cessation and the Department of Health’s Stop smoking service delivery and monitoring guidance 2011/12
  • If someone does not want, is not ready or is unable to stop smoking in one step, ask if they would like to consider a harm-reduction approach. If they agree, help them to identify why they smoke, their smoking triggers and their smoking behaviour. Use this information to work through the harm-reduction approaches outlined in Harm reduction approaches covered by guidance
  • Use professional judgement to suggest which approach(es) might be most suitable, based on the person’s smoking behaviour, experience of previous quit attempts and their health and social circumstances. Briefly discuss the merits of each approach to help them choose
  • Ensure people know that licensed nicotine-containing products (such as nicotine patches, gum, or spray) make it is easier to cut down prior to stopping, or to reduce the amount they smoke. Explain that using these products also helps avoid compensatory smoking and increases the chances of stopping in the longer term
  • Recommend one or more licensed nicotine-containing products. If possible, supply or prescribe these products. Otherwise, encourage people to ask their GP or pharmacist for them, or tell them where they can buy the products themselves (see Supplying licensed nicotine-containing products)
  • Advise people that they can continue to use licensed nicotine-containing products in the long term, rather than risk relapsing after they have stopped, or reduced their smoking
  • If more intensive support is required, offer a referral to stop smoking services. These services provide pharmacotherapies and more comprehensive support and advice about harm reduction and stopping smoking in the longer term

Behavioural support

  • 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. (See the Department of Health’s Stop smoking service delivery and monitoring guidance 2011/12)
  • Use the information gathered 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 or choosing periods during the day, or specific occasions, when they will not smoke
  • Help people who are cutting down prior to stopping smoking to set a specific quit date. The quit date should normally be within 6 weeks from the start of receiving 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
  • 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
  • Tell people who are not prepared to stop smoking that the health benefits from smoking reduction are unclear. However, 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 licensed nicotine-containing products to help reduce the amount they smoke
  • Where necessary, advise people how to use licensed nicotine-containing products effectively
  • Offer follow-up appointments to review progress and support people who have adopted a harm-reduction approach (see Follow-up appointments)

Advising on licensed nicotine-containing products

  • Reassure people who smoke that licensed nicotine-containing products are a safe and effective way of reducing the amount they smoke. Advise that they can be used as a complete or partial substitute for tobacco, either in the short or long 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
  • Explain how to use licensed nicotine-containing products correctly. This includes ensuring people know how to achieve a sufficiently high dose to control cravings, prevent compensatory smoking and achieve their goals on stopping or reducing the amount they smoke
  • Explain that people can use one product on its own or a combination of different ones. Advise them that using more than one product is more likely to be successful, particularly for more dependent smokers. (Some products are fast acting and deal better with immediate cravings, whereas others are long acting and provide a steadier supply of nicotine)
  • Advise people to replace each cigarette with a licensed nicotine-containing product, 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
  • Advise people that licensed nicotine-containing products can be used for as long as they help reduce the desire to smoke—and for the long term, if necessary, to prevent relapse
  • Tell people that some nicotine-containing products are not regulated by the MHRA and, therefore, their effectiveness, safety and quality cannot be assured. Also advise them that these products are likely to be less harmful than cigarettes

Supplying licensed nicotine-containing products

  • Offer all types of licensed nicotine-containing products to people who smoke, as part of a harm-reduction strategy (either singly or in combination). Take into account their preference and level of dependence. As an example, patches could be offered with gum or lozenges
  • Offer licensed nicotine-containing products, as necessary, to help prevent a relapse among people who have stopped smoking or reduced the amount they smoke. (This includes people who have stopped smoking in one step or by cutting down prior to stopping)

Follow-up appointments

  • Follow people up to see whether they have achieved their goal(s). If those who set out to reduce the amount they smoke (or to abstain temporarily) have been successful, assess their motivation to maintain that level, to further reduce the amount they smoke or to stop smoking
  • Use professional judgement about the number, timing and frequency of appointments offered
  • At appropriate intervals, measure exhaled carbon monoxide level to gauge people’s progress and help motivate them. 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 reducing their smoking and, where appropriate, to encourage a further reduction or stopping completely
  • Encourage people who have not achieved their goals to try again. Also discuss whether they would like to continue using the same licensed nicotine-containing product or try a different one (or a different combination of products)

Supporting temporary abstinence

  • Offer people who want (or need) to abstain temporarily on a short-, medium- or longer-term basis advice on how to do this*. Include information about the different types of licensed nicotine-containing products and how to use them (see Advising on licensed nicotine-containing products). Where possible, prescribe them (see Supplying licensed nicotine-containing products)
  • Offer behavioural support to people who want (or need) to abstain temporarily. Support may be provided in one-to-one or group sessions by specialist services (see Behavioural support). It could include discussing why it is important to reduce the harm caused by smoking (to others as well as themselves). It could also include encouraging people to consider other times or situations when they could abstain
  • Offer follow-up appointments (see Follow-up appointments)

* People might temporarily abstain in the short-term to comply with smokefree policies, for example, at work. Medium-term temporary abstinence may occur when admitted to hospital. Long-term temporary abstinence might occur during a custodial sentence.

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/PH45

National Institute for Health and Care Excellence. Smoking: harm reduction. June 2013
First included: October 13.