This Guidelines summary covers the key points for primary care. Please refer to the full guideline for recommendations on:
- preventing young people from taking up smoking
- mental health
- offender health
- workplace interventions
- questions to check if you are following evidence and best practice
- supporting people to stop smoking
- commissioning comprehensive local tobacco control interventions
- Effective local systems are required to move the tobacco control agenda forward
- Formal strategic partnerships for tobacco control should involve all the relevant stakeholders and agencies (such as acute health, mental health, public health, regulatory services, employment, social care, children’s services, fire and rescue service and criminal justice)
Aim of this guidance
- This guidance, along with the data packs that are sent directly to local authorities, 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
- Local authorities and their partners are also encouraged to adopt CLeaR, an, an evidence-based improvement model which can assist in evaluating the effectiveness of local action addressing harm from tobacco
Commissioning comprehensive local tobacco control interventions
- For smoking cessation to happen, smokers need to have the capability, opportunity and motivation to change. All three of these need to be in place. This broad principle has been captured by the COM-B model of behaviour
- Figure 1 (below) shows the COM-B model applied to smoking cessation in a given population or sub-population (for example, low income smokers, smokers with mental health problems or pregnant smokers)
- Capability refers to smokers’ ability to stop if they try. This depends on their level of addiction to cigarettes. Most smokers are addicted to some degree, so treating the addiction will improve their chances of success. Some smokers are much more heavily addicted than others and it is essential that these people have access to specialist support
- Motivation refers to smokers’ desire to try to stop now rather than at some other time or never. Creating a sense of immediacy and hope are important in prompting quit attempts. Examples include:
- social marketing via mass media, social media and other platforms—these are leading factors in motivating a person to quit, working by reminding them about quitting, the best ways to do it, and prompting a quit attempt
- minimising access to cheap tobacco—this supports one of the main influences for quitting: the financial cost
- brief advice from a healthcare professional—this is still one of the most important triggers to quitting, especially if it involves the offer of support
- There is a high level of interaction between these elements, emphasising the need for comprehensive local tobacco control action plans. Improving smokers’ ability to stop can increase their motivation to try, as can decreasing smoking triggers in their environment and increasing public visibility of quitting
- The most effective tobacco control strategy is one in which all the elements are working together. This means, for example, linking up social marketing campaigns prompting quitting with brief advice from health professionals offering support. An integrated strategy requires multi-agency working with a clear and coherent vision as to the local objectives and how the different elements of the strategy will combine to achieve these
- Do interventions commissioned for tobacco control and tackling smoking-related harm take an evidence-based approach based on NICE guidance and National Centre for Smoking Cessation and Training (NCSCT) commissioning recommendations?
- Are reliable cost-effectiveness data tools used to inform commissioning decisions and ensure that investment in tobacco control is based on an understanding of expenditure, performance and effectiveness?
- Do contracts for commissioned services specify performance indicators and are these regularly monitored and reviewed?
- Are interventions and services geographically and culturally appropriate to the people for whom they are designed?
- Is there sufficient tobacco control commissioning capacity and expertise?
- Are arrangements in place to enable commissioning with regional partners?
- Does formal evaluation of the range of tobacco control interventions feature in the commissioning strategy?
Supporting people to stop smoking
- Targeted stop smoking services, as an integral part of any comprehensive tobacco control strategy, provide evidence-based support tailored to the needs and preferences of smokers
The need for tailored quitting support within a comprehensive strategy
- The probability of one-year success of an unaided quit attempt is typically less than 5%. That is a main reason why smoking prevalence is falling very slowly despite the fact that a third of smokers try to stop every year
Smoking cessation within integrated lifestyle services
- It is essential that commissioning decisions take account of the large body of evidence on the effectiveness and cost-effectiveness of different approaches
- The NCSCT has reviewed this literature and provided recommendations. It concludes that smoking cessation is most effective and cost-effective when provided as a single intervention, rather than as part of multi-component integrated lifestyle interventions. The evidence associated with different components and models for providing stop smoking interventions is summarised in this PHE models of delivery guidance
Harm reduction and the role of e-cigarettes in supporting smokers to quit
- NICE tobacco harm reduction guidance PH45 sets out a series of approaches that support smokers to quit in the longer term, while reiterating that abrupt quitting is the best option:
- stopping smoking and using one or more licensed nicotine-containing products as long as needed to prevent relapse
- cutting down prior to stopping smoking with or without the help of licensed nicotine-containing products
- smoking reduction with or without the help of licensed nicotine-containing products
- temporary abstinence from smoking with or without the help of licensed nicotine-containing products
- In the context of tobacco control in the UK, harm reduction involves:
- advising smokers who are not ready to quit that they should try to reduce their smoking with the aid of a nicotine substitute
- recognising that smokers who have stopped smoking with the aid of a nicotine substitute may need to continue to use that substitute for months or years to prevent relapse to smoking
- Leading UK health and public health organisations including the Royal College of General Practitioners, the British Medical Association and Cancer Research UK now agree that although they are not risk free, e-cigarettes are far less harmful than smoking
- E-cigarettes cannot be prescribed to smokers as part of stop smoking interventions, as there are currently no medicinally licensed products available on the market. However some services provide e-cigarette starter packs, increasing footfall and improving quit rates. Clear advice on the benefits and risks should be included in optimal self-support, and stop smoking services should welcome smokers who want to use an e-cigarette to help them quit
- NICE guidance NG92 ‘Stop smoking interventions and services’ recommends that health and social care professionals provide the following advice to smokers who are using, or interested in using, an e-cigarette for quitting. The guidance says that:
- although these products are not licensed medicines, they are regulated by the Tobacco and Related Products Regulations 2016
- many people have found them helpful to quit smoking cigarettes
- people using e-cigarettes should stop smoking tobacco completely, because any smoking is harmful
- the evidence suggests that e cigarettes are substantially less harmful to health than smoking but are not risk free
- the evidence in this area is still developing, including evidence on the long-term health impact
- Further guidance is available from the National Centre for Smoking Cessation and Training (NCSCT)
What you will see if you are meeting the principle
- In line with NICE guidance, service providers should treat at least 5% of their local smoking population and see the following indicators in their area:
- stop smoking services achieve exhaled carbon monoxide (CO) validated success rates comparable to areas with similar smoker profiles and within the nationally prescribed range
- stop smoking support is routinely offered, and made easily accessible, to vulnerable populations and those identified as at risk in the needs assessment
- all licensed stop smoking medications are available as first-line treatment options, especially dual form nicotine replacement therapy (NRT) (for example, nicotine transdermal patch plus a faster-acting product), and varenicline
- people who are using or want to use e-cigarettes to stop smoking receive advice and behavioural support from their local stop smoking service
- services are independently audited and improvement plans are implemented where required
- there are clear and efficient referral pathways embedded throughout health and social care services and these are routinely used to promote stop smoking services
- services are promoted locally through mass media channels to raise awareness of the support available for people who want to stop smoking
- there is simple, easy-to-use online information for smokers to get information about the stop smoking support available in their area, the benefits of using each of the options, the commitment required for each and how to access them
- the role of stop smoking support in the local tobacco control strategy is clearly set out, quantifying how it is expected to contribute to reducing overall smoking prevalence and in different sub-populations
- all required monitoring data is reported to NHS Digital through the quarterly reporting system
- smokers who are not ready, willing, or able to stop in one step are advised and supported to use a licensed nicotine-containing product or an e-cigarette to help them reduce their smoking with a view to stopping in the future
- ex-smokers who feel they need to continue to use a nicotine substitute long term to avoid relapse to smoking are encouraged to do so
Supporting pregnant smokers and those with infants to stop smoking
- All women who smoke and are pregnant, planning a pregnancy and have an infant should be referred for help to stop smoking
Reducing smoking in pregnancy is an urgent priority
- Addressing smoking in pregnancy should be a focus for all localities as this impacts on a range of issues related to health, inequalities and child development. NICE has produced guidance on how best to support women to stop smoking in pregnancy
Support is needed for pregnant smokers
- Using the COM-B model, there needs to be a much greater emphasis on capability and opportunity
- Pregnant women who continue to smoke should receive the highest quality stop smoking support available based on evidence-based principles set out in NICE and NCSCT guidance. The healthcare system should support broader strategies to address this issue, creating a social environment in which smoking during pregnancy is not normal, but quitting is. This requires repeated offers of support for quitting, delivered in a way that inspires hope rather than making people feel guilty
- Relapse to smoking soon after the baby is born is very common, but can be reduced by appropriate interventions from healthcare professionals working with new mothers. This kind of support should form part of a comprehensive programme commissioned by local authorities and embedded within the local maternity system
What you will see if you are meeting the principle
- Smoking is addressed by all healthcare professionals working with pregnant women throughout their pregnancy
- All pregnant women are screened for carbon monoxide (CO) at their booking appointment, and at subsequent antenatal appointments. If elevated CO levels are identified (indicating smoking) a referral is made to a specially trained pregnancy stop smoking advisor for support to stop
- Robust, opt-out referral pathways are in place between the healthcare professional (HCP) who raises the issue of smoking with the pregnant woman and the stop smoking service or person trained to provide the intervention. This will include feedback mechanisms to ensure the referring HCP is aware of the outcome
- Partners and family members who smoke are also offered support to stop smoking and information is provided on the risks associated with secondhand smoke
Smokefree homes and cars
- Enclosed smokefree places or settings create an environment in which smoking is less normal and protect the health of non-smoking children and adults
Enclosed smokefree environments protect non-smokers and promote quitting
- Millions of children in the UK are still exposed to secondhand smoke that puts them at increased risk of respiratory problems, meningitis and sudden unexplained infant death, according to a Royal College of Physicians report ‘Passive smoking and children’ published in 2010. Each year this results in over 300,000 GP visits and around 9500 hospital admissions in the UK and costs the NHS more than £23.6 million
- Exposure to secondhand smoke in confined spaces such as a car is particularly hazardous
What you will see if you are meeting the principle?
- Frontline health and social care workers routinely ask service users if they are ever exposed to tobacco smoke in an enclosed environment
- Frontline health and social care workers provide expert advice on how to make homes and cars smokefree
- Local policies and plans are in place to increase enclosed smokefree spaces, supporting smokers to create and maintain smokefree homes and cars
- Local partners are in a position to educate the public on compliance with smokefree legislation, including the prohibition of smoking in a vehicle with someone under the age of 18 present
- Primary care remains a main source of evidence-based advice and support about smoking and action must be properly integrated with other tobacco control activities
What will you see locally if you are meeting the principle?
- GPs identifying smokers, delivering very brief advice and following up, where appropriate, with a referral into stop smoking services, in accordance with NICE guidance NG92 ‘Stop smoking interventions and services’
- GPs offering advice on using nicotine-containing products on general sale, including NRT and e cigarettes, in accordance with NICE guidance NG92
- All evidence-based support options are available to smokers through primary care and smokers are clear about what they involve and the benefits of each
- As part of the NHS Health Check for adults aged 40 to 74, all smokers are given advice and offered a referral to their local stop smoking service
- Patients who decline support are advised to reduce their smoking with the aid of a licensed nicotine product or, if they prefer, an e-cigarette
- All GPs have completed the NCSCT ‘Very brief advice on smoking’ online training module
Questions to check if you are following the evidence and best practice
- Is the smoking status of all patients known?
- Are records routinely updated to ensure that the smoking status of all patients is accurate?
- Are all patients who smoke offered very brief advice on stopping smoking?
- Are patients who smoke offered advice on using nicotine-containing products on general sale, including NRT and e-cigarettes?
- Is there access to a freely available and evidence-based stop smoking service for everyone who smokes or uses tobacco in any other form?
- Have any barriers to accessing stop smoking support been identified?
- Is referral to a stop smoking service made where support is required?
- Is referral recorded on the patient’s records and is the outcome of the intervention recorded?
- Have all in-house stop smoking practitioners been trained to NCSCT standards?
CLeaR model for tobacco control
- 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 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
- CLeaR was updated in November 2017 to make it more relevant to all partners working in tobacco control. As part of the work, a series of ’deep dive’ tools were developed. These tools follow the same design as the generic CLeaR improvement tool but, rather than cover the breadth of tobacco control, they focus on specific issues. They currently cover:
- smoking in pregnancy
- smoking in acute settings
- smoking in mental health settings
© Crown copyright 2019 Public Health England. Tobacco commissioning support 2019 to 2020: principles and indicators. Available from: www.gov.uk/government/publications/alcohol-drugs-and-tobacco-commissioning-support-pack/tobacco-commissioning-support-pack-2019-to-2020-principles-and-indicators
Contains public sector information licensed under the Open Government Licence v3.0
First published: 04 October 2018.