Tobacco: Preventing Uptake, Promoting Quitting and Treating Dependence

Overview

This updated Guidelines summary includes recommendations on promoting quitting, treating tobacco dependence, adherence and relapse prevention, and treating tobacco dependence in pregnant women.

It does not cover using tobacco products; preventing uptake; promoting stop-smoking support; promoting support for people to stop using smokeless tobacco; supporting people who do not want, or are not ready to stop smoking (harm reduction); or support to stop smoking in secondary care services. For recommendations in these areas, refer to the full guideline.

In August 2022, varenicline was unavailable in the UK. See the Medicines and Healthcare products Regulatory Agency (MHRA) alert on varenicline. 

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Promoting Quitting

These recommendations promote options to help people stop smoking or using smokeless tobacco or, if they do not want or are not ready to stop in one go, to reduce their harm. They are for people working in public health, and others with tobacco control and providing advice about harm reduction as part of their remit. 

For recommendations on preventing uptake, refer to the full guideline.

Using Medicinally Licensed Nicotine-containing Products

• Raise public awareness of the harm caused by smoking and secondhand smoke. Make it clear that smoking causes a range of diseases and conditions including cancer, chronic obstructive pulmonary disease and cardiovascular disease.
• Provide information on how people who smoke can reduce the risk of illness and death (to themselves and others) by using 1 or more medicinally licensed nicotine-containing products. Explain that they could be used as a partial or complete substitute for tobacco, either temporarily or in the long term.
• Provide the following information about nicotine:
  • smoking is highly addictive mainly because it delivers nicotine very quickly to the brain and this makes stopping smoking difficult
  • most smoking-related health problems are caused by other components in tobacco smoke, not by the nicotine
  • nicotine levels in medicinally licensed nicotine-containing products are much lower than in tobacco, and the way these products deliver nicotine makes them less addictive than smoking.
• Provide the following information about the effectiveness and safety of medicinally licensed nicotine-containing products:
  • any risks from using medicinally licensed nicotine-containing products are much lower than those of smoking; nicotine replacement therapy (NRT) products have been demonstrated in trials to be safe to use for at least 5 years
  • lifetime use of medicinally licensed nicotine-containing products is likely to be considerably less harmful than smoking.
• Provide information on using medicinally licensed nicotine-containing products, including:
  • what forms they take
  • how to use them effectively when trying to stop or cut down smoking
  • long-term use to reduce the risk of relapsing
  • where to get them
  • the cost compared with smoking.

For recommendations on what information to provide about nicotine-containing e-cigarettes, see the section on advice on nicotine-containing e-cigarettes.

For recommendations on promoting stop-smoking support and promoting support for people to stop using smokeless tobacco, refer to the full guideline.

Treating Tobacco Dependence

These recommendations aim to help people aged 12 or over (unless otherwise stated) to stop smoking or, if they do not want or are not ready to stop in one go, to reduce their harm from smoking.

Identifying and Quantifying People’s Smoking

Identifying People Who Smoke

These recommendations are for health and social care professionals and those providing stop-smoking support or advice (for recommendations about pregnant women see the section on identifying pregnant women who smoke and referring them for stop-smoking support).

• At every opportunity, ask people if they smoke or have recently stopped smoking.
• 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.
• Discuss any stop-smoking aids the person has used before, including personally purchased nicotine-containing products.
• Offer advice on using nicotine-containing products on general sale, including over-the-counter nicotine replacement therapy (NRT) and nicotine-containing e-cigarettes.
• 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 in the full guideline)
  • 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.
• Record smoking status and all actions, discussions and decisions related to advice, referrals or interventions about stopping smoking.
• Ask about their smoking status at the next available opportunity.

Identifying Smoking Among Carers, Family and Other Household Members

These recommendations are for anyone who is responsible for providing health and support services (including stop-smoking support) to people using acute, maternity or mental health services.

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

Stop-smoking Interventions

These recommendations are for people providing stop-smoking support or advice. For training requirements, see the National Centre for Smoking Cessation and Training (NCSCT) standard for training in smoking cessation treatments.

For recommendations on digital and mobile health interventions for stopping smoking, see NICE’s guideline on behaviour change: digital and mobile health interventions.

See the full guideline for advice on people’s use of prescribed medicines that are affected by smoking (or stopping smoking).

• Tell people who smoke that a range of interventions is available to help them stop smoking. Explain how to access them and refer people to stop-smoking support if appropriate.
• Ensure the following are accessible to adults who smoke:
  • behavioural interventions:
    • behavioural support (individual and group)
    • very brief advice
  • medicinally licensed products:
    • bupropion (see BNF information on bupropion hydrochloride)
    • nicotine replacement therapy – short and long acting
    • varenicline (see NICE’s technology appraisal guidance on varenicline for smoking cessation and the BNF information on varenicline)
    • nicotine-containing e-cigarettes
    • Allen Carr's Easyway in-person group seminar.
      
      In August 2022, varenicline was unavailable in the UK. See the MHRA alert on varenicline.
• Consider NRT for young people aged 12 and over who are smoking and dependent on tobacco. If this is prescribed, offer it with behavioural support.
• Do not offer varenicline or bupropion to people under 18.
• Offer behavioural support to people who smoke regardless of which option they choose to help them stop smoking, unless they have chosen the Allen Carr Easyway in-person group seminar. Explain how to access this support.
• Discuss with people which options to use to stop smoking, taking into account:
  • their preferences, health and social circumstances
  • any medicines they are taking
  • any contraindications and the potential for adverse effects
  • their previous experience of stop-smoking aids.Also see the advice in the recommendations on medicinally licensed products, and the recommendations on nicotine-containing e-cigarettes.
• Advise people (as appropriate for their age) that the following options, when combined with behavioural support, are more likely to result in them successfully stopping smoking:
  • varenicline (offered in line with NICE’s technology appraisal guidance on varenicline for smoking cessation)
  • a combination of short-acting and long-acting NRT
  • nicotine-containing e-cigarettes.
    
    In August 2022, varenicline was unavailable in the UK. See the MHRA alert on varenicline.
• Advise people (as appropriate for their age) that the options that are less likely to result in them successfully stopping smoking, when combined with behavioural support, are:
  • bupropion
  • short-acting NRT used without long-acting NRT
  • long-acting NRT used without short-acting NRT.
• For adults, prescribe or provide bupropion, varenicline or NRT before they stop smoking:
  • For bupropion agree a quit date set within the first 2 weeks of treatment, reassess the person shortly before the prescription ends.
  • For varenicline agree a quit date and start the treatment 1 to 2 weeks before this date, reassess the person shortly before the prescription ends.
  • For NRT agree a quit date and ensure the person has NRT ready to start the day before the quit date.
    
    In August 2022, varenicline was unavailable in the UK. See the MHRA alert on varenicline.

Advice on Medicinally Licensed Products

These recommendations are for people providing stop-smoking support or advice.

• 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.
• 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.
• 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.

Advice on Nicotine-containing E-cigarettes 

These recommendations are for people providing stop-smoking support or advice to adults.

• 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 Office for Health Improvement and Disparities’ information on e-cigarettes and vaping).
• 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.
• 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.
• 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.
• 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.

Support to Stop Smoking in Primary Care and Community Settings

This recommendation is for health and social care professionals in primary care and community settings. See the full guideline for advice on people’s use of prescribed medicines that are affected by smoking (or stopping smoking).

Other recommendations to support pregnant women to stop smoking are in the section on treating tobacco dependence in pregnant women.

• For people who want to stop smoking:
  • discuss with them how they can stop (NCSCT programmes explain how to do this)
  • provide stop-smoking interventions and advice; see the section on stop-smoking interventions
  • if you are unable to provide stop-smoking interventions, refer them to local stop-smoking support, if available
  • if they opt out of a referral to stop-smoking support, refer them to a professional who can offer pharmacotherapy and very brief advice.

For recommendations on support to stop smoking in secondary care services, and supporting people who do not want, or are not ready, to stop smoking in one go, refer to the full guideline.

Stopping Use of Smokeless Tobacco

Identifying People who Use Smokeless Tobacco and Offering Referral

These recommendations are for GPs, dentists, pharmacists and other healthcare professionals, particularly those providing services for South Asian communities.

• 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.
• 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.
• 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.
• 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).

Adherence and Relapse Prevention

These recommendations are for people providing stop-smoking support or advice.

Supporting People Trying to Stop Smoking

• 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.
• 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.

Supporting People Cutting Down or Stopping Temporarily

• 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.
• 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.
• Offer medicinally licensed nicotine-containing products, as needed, to help prevent a relapse among people who have reduced the amount they smoke.

Reviewing the Approach for People Trying to Stop Smoking, Cutting Down or Stopping Temporarily

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

Treating Tobacco Dependence in Pregnant Women

Identifying Pregnant Women Who Smoke and Referring Them for Stop-smoking Support

These recommendations are for healthcare professionals providing maternity care, and aim to help women stop smoking during pregnancy and in the first year after childbirth.

• Provide routine carbon monoxide testing at the first antenatal appointment and at the 36-week appointment to assess every pregnant woman's exposure to tobacco smoke. Provide carbon monoxide testing at all other antenatal appointments if the pregnant woman:
  • smokes or
  • is quitting or
  • used to smoke or
  • tested with 4 ppm or
  • above at the first antenatal appointment.
• Provide routine carbon monoxide testing at all antenatal appointments to assess the pregnant woman’s exposure to tobacco smoke.
• Provide an opt-out referral to receive stop-smoking support for all pregnant women who:
  • say they smoke or have stopped smoking in the past 2 weeks or
  • have a carbon monoxide reading of 4 ppm or above or
  • have previously been provided with an opt-out referral but have not yet engaged with stop-smoking support.
    
    See also the section on identifying smoking among carers, family and other household members.
• Explain to the woman:
  • that it is normal practice to refer all pregnant women who smoke or have recently quit
  • that the carbon monoxide test will allow her to see a physical measure of her smoking and exposure to other people’s smoking
  • what her carbon monoxide reading means, taking into consideration the time since she last smoked and the number of cigarettes smoked (and when) on the day of the test.
• If the pregnant woman does not smoke but has a carbon monoxide level of 3 ppm or more, help her to identify the source of carbon monoxide and reduce it. (Other sources include household or other secondhand smoke, heating appliances or traffic emissions.)
• If the pregnant woman has a high carbon monoxide reading (more than 10 ppm) but says she does not smoke:
  • advise her about possible carbon monoxide poisoning
  • ask her to contact the Gas Emergency Line (0800 111 999) for gas safety advice
  • phrase any further questions about smoking sensitively to encourage a frank discussion.
• Record carbon monoxide level and any feedback given in the pregnant woman’s antenatal records. If her antenatal records are not available locally, use local protocols to record this information.

For recommendations on following up pregnant women who have been referred to stop smoking support, refer to the full guideline.

Providing Support to Stop Smoking

These recommendations are for people providing stop-smoking support or advice.

• Provide the pregnant woman with intensive and ongoing support (brief interventions alone are unlikely to be sufficient) throughout pregnancy and beyond. This includes regularly monitoring her smoking status using carbon monoxide tests. Use carbon monoxide measurements to encourage her to quit and as a way to provide positive feedback once a quit attempt has been made.
• Biochemically validate that the pregnant woman has quit on the date she set and 4 weeks after. If possible, use urine or saliva cotinine tests, as these are more accurate than carbon monoxide tests. (They can detect exposure over the past few days rather than hours.)
• When carrying out tests, check whether the pregnant woman is using nicotine replacement therapy (NRT) as this may raise her cotinine levels. Take into account that no measure can be 100% accurate. Some people may smoke so infrequently – or inhale so little – that their intake cannot reliably be distinguished from that from passive smoking.
• If the pregnant woman stopped smoking in the 2 weeks before her maternity booking appointment, continue to provide support in line with the recommendations above and stop-smoking support practice protocols.
• Establish links with contraceptive services, fertility clinics and antenatal and postnatal services so that everyone working in those organisations knows about local stop-smoking support. Ensure they understand what these services offer and how to refer people to them.

For pregnant women taking prescribed medicines, also see the section on medicine dosages for people who have stopped smoking in the full guideline.

Nicotine Replacement Therapy and Other Pharmacological Support

• Consider NRT alongside behavioural support to help women stop smoking in pregnancy (see BNF information on NRT).
• Consider NRT at the earliest opportunity in pregnancy and continue to provide it after pregnancy if the woman needs it to prevent a relapse to smoking, including if the pregnancy does not continue (see BNF information on NRT).
• Give pregnant women clear and consistent information about NRT. Explain:
  • that it may help them stop smoking and reduce their cravings
  • how to use NRT correctly, including how to get a high enough dose of nicotine to control cravings, prevent compensatory smoking and stop successfully.
• Advise pregnant women who are using nicotine patches to remove them before going to bed.
• Emphasise to pregnant women that:
  • most smoking-related health problems are caused by other components in tobacco smoke, not by the nicotine
  • any risks from using NRT are much lower than those of smoking
  • nicotine levels in NRT are much lower than in tobacco, and the way these products deliver nicotine makes them considerably less addictive than smoking.
• Do not offer varenicline or bupropion to pregnant or breastfeeding women.

Incentives to Stop Smoking

These recommendations are for providers of stop-smoking support.

• In addition to NRT and behavioural support, offer voucher incentives to support women to stop smoking during pregnancy, as follows:
  • refer women to an incentive scheme at the first maternity booking appointment or at the next available opportunity
  • provide vouchers only for abstinence validated using a biochemical method, such as a carbon monoxide test with a reading of less than 4 ppm
  • stagger incentives until at least the end of pregnancy (incentives totalling around £400 have been shown to be effective)
  • do not exclude women who have relapsed or those whose pregnancy does not continue from continuing to take part in the scheme and try again
  • ensure vouchers cannot be used to buy products that could be harmful during pregnancy (for example, alcohol and cigarettes).
• Consider providing voucher incentives jointly to the pregnant woman and to a friend or family member that she has chosen to support her during her quit attempt.
• Ensure staff are trained to promote and deliver incentive schemes to pregnant women to stop smoking.

Enabling All Pregnant Women to Access Stop-smoking Support

These recommendations are to help providers of stop-smoking support reach all pregnant women, including those whose circumstances may make it more difficult to use services (for example, because of cultural or sociodemographic factors, age or language).

• Involve pregnant women who find it difficult to use or access existing stop-smoking support in the planning and development of services.
• Collaborate with the family nurse partnership and other outreach schemes to identify additional opportunities for providing intensive and ongoing support to pregnant women to stop smoking. (Note: family nurses make frequent home visits.)
• Work in partnership with agencies that support pregnant women who have complex social and emotional needs. This includes substance misuse services, youth and teenage pregnancy support and mental health services.

Helping Partners and Others in the Household Who Smoke

These recommendations are for providers of stop-smoking support. See also the section on identifying smoking among carers, family and other household members.

• Offer pregnant women’s partners who smoke help to stop. Use an intervention that comprises 3 or more elements and multiple contacts. Discuss with them which options to use – and in which order, taking into account:
  • their preferences
  • contraindications and the potential for adverse effects from stop-smoking pharmacotherapies
  • the likelihood that they will follow the course of treatment
  • their previous experience of stop-smoking aids
  • do not favour one course of treatment over another; together, choose the one that seems most likely to succeed taking into account the above.

For recommendations on policy, commissioning, and training, refer to the full guideline.