Guidance

Smoking and tobacco: applying All Our Health

Updated 5 April 2022

The Public Health England team leading this policy transitioned into the Office for Health Improvement and Disparities (OHID) on 1 October 2021.

1. Introduction

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 to:

• understand the specific activities and interventions that support a smoker to quit
• access training resources to support your learning and 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 in strategic roles can take.

The All Our Health: personalised care and population health collection contains 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.

The Office for Health Improvement and Disparities (OHID) and Health Education England’s ‘elearning for healthcare’ developed this e-learning to increase the confidence and skills of health and care professionals, to make prevention part of their day-to-day practice.

Completing this session will count towards your continued professional development.

3. Why you should 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 disadvantaged communities and groups.

Despite a continued decline in smoking prevalence, 13.9% of adults in England still smoke. This equates to over 6 million people in 2019.

Smoking is the leading preventable cause of illness and premature death, killing around 74,600 people in England in 2019. US data indicates that for every death caused by smoking, at least 30 smokers are living with a serious smoking-related illness.

In England in 2019 to 2020, there were an estimated 506,100 smoking-related admissions to hospital, equating to almost 1,400 each day. One in 4 patients in a hospital bed is a smoker. Smokers also see their GP 35% more than non-smokers.

Stopping smoking at any time has considerable health benefits, including for people with a pre-existing smoking-related disease. 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
• fewer re-admissions after surgery

Smoking is not a lifestyle choice but a dependency requiring treatment. This was recognised in 2017 by the government’s commitment for the NHS in England to become smoke-free. 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. This will make a vital contribution to realising the government’s ambition to achieve a smoke-free society in England by 2030, defined as adult smoking prevalence of 5% or less.

4. Harm to health caused by 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. It leads to decreased bone mineral density and is associated with increased risk of osteoporosis, bone fractures, back pain and degenerative disc disease.

National data shows that smoking is also closely associated with poor mental health and wellbeing. Smokers score worse than the population as a whole on every mental wellbeing indicator.

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 also harmful to mental health and wellbeing. National data shows that smokers score worse than the population as a whole on every mental wellbeing indicator.

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

4.1 Smoking during pregnancy

Smoking is the 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
• sudden infant death syndrome

Around 1 in 10 babies in England is born to a mother who smoked throughout her pregnancy.

4.2 Smoking among people with mental health problems

People with mental health problems are almost 2.5 times as likely to smoke as the general population. Smoking rates increase with the severity of mental illness. Among adults with a serious mental illness, 40.5% smoke. The high smoking rate among people with mental health conditions is the 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.

5. Quitting smoking: the importance of support

Over half (52.7%) of smokers say they want to quit, and 1 in 5 intends to do so within 3 months. Currently, around half of all smokers in England try to quit with no help, just using willpower alone, despite this being the least effective method.

Being encouraged by a healthcare professional is one of the most important motivational factors for someone who wants to quit smoking. The success of quit attempts can be significantly increased by helping patients identify and access appropriate quit aids and further support.

Stop smoking options: guidance for conversations with patients was published to support conversations between clinicians and people who smoke on what method to choose to help them quit.

5.1 Treating tobacco dependence in the NHS

The NHS Long Term Plan sets out the commitment that by 2023 to 2024, all people admitted to an acute or mental health hospital who smoke will be offered NHS funded tobacco dependency treatment (based on the Ottawa Model for Smoking Cessation). NHS staff will deliver stop smoking support during and after the hospital stay and refer the patient into community stop smoking support when they are discharged.

The model will also be adapted for expectant mothers and their partners, with a new smoke-free pregnancy pathway. This will include focused sessions and treatments delivered in maternity settings.

Specialist mental health services, including learning disability services, will offer outpatient stop smoking support from 2022 to 2023.

The gradual rollout of these NHS Long Term Plan commitments began in 2020, with a phased approach. The aim is to cover 100% of relevant smokers by 2023 to 2024.

Primary care is a crucial part of the prevention pathway and will reach a larger number of healthier and younger smokers. Cost-effective smoking cessation interventions can be delivered simply and quickly through primary care to help reduce the number of people who smoke.

5.2 Local stop smoking services

Expert support from a local stop smoking service gives smokers the best chance of quitting for good, making them 3 times as likely to succeed as if they try to quit without any help.

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.

5.3 Stop smoking aids

There is a wide range of stop smoking aids available, including:

• nicotine replacement therapy (NRT) products such as patches, sprays, lozenges and gum
• e-cigarettes (vapes)
• prescription tablets Varenicline (Champix) and Bupropion (Zyban)

Using a stop smoking medicine prescribed by a healthcare professional doubles a smoker’s chances of quitting.

E-cigarettes (vapes)

E-cigarettes are the most commonly used quit aid among smokers in England and there is growing evidence of their effectiveness. An updated Cochrane Review published in 2021 found that nicotine-containing e-cigarettes are around twice as effective in supporting smokers to quit as NRTs such as patches and gum.

E-cigarettes are not licensed as medicines in the UK, but they are tightly regulated for safety and quality. Most of the poisonous chemicals contained in tobacco smoke, including tar and carbon monoxide, are not in e-cigarette vapour. The chemicals that are in e-cigarette vapour are at much lower levels than in tobacco smoke.

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 e-cigarettes are not risk-free, they are far less harmful than cigarettes.

National Institute for Health and Care Excellence (NICE) guideline Tobacco: preventing uptake, promoting quitting and treating dependence (NG209) includes recommendations on the advice that health and care professionals should provide to smokers on using e-cigarettes to quit.

5.4 The evidence on nicotine

The evidence shows that while nicotine is the addictive substance in cigarettes, it is relatively harmless. 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 a third of smokers know that NRT is much less harmful than cigarettes

Advising smokers on the relative risks of nicotine-containing products compared to smoked tobacco is an important part of supporting them to quit.

6. 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

7. Taking action

7.1 If you’re a front-line health and care professional

As a health and care professional, you are best placed to motivate and support smokers on their quit journey. All health and care professionals should identify and refer smokers using the method known as very brief advice (VBA), This has 3 components: ask, advise and act.

1. Ask and record smoking status. Is the patient a smoker, ex-smoker or non-smoker?
2. Advise on the best way of quitting. The best way of stopping smoking is with a combination of stop smoking aids and specialist support.
3. Act on patient response. Build confidence, give information, refer and prescribe.

You should undertake the 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.

You should make the most of existing opportunities including NHS Health Check and the Quality and Outcomes Framework to include tackling smoking in routine clinical care.

If you are a health and care professional working in a hospital, you should be familiar with the NHS trust’s operational procedures and policies for treating tobacco dependence and how to advise, record and initiate quitting support.

Specific training for front-line NHS staff, linked to the NHS Long Term Plan, is currently being developed by NHS England and NHS Improvement. This will cover training for staff delivering VBA to patients on admission, as well as more in-depth training for those delivering the more intensive package of tobacco dependency treatment.

You should be aware of the quitting support available in your area and be able to refer smokers for specialist support. Ask your team leader or manager for this information.

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 all women have their carbon monoxide (CO) monitored, and refer those with elevated levels for specialist stop smoking support. Also, make sure all members of the midwifery team:

• are trained to use the CO monitor
• have brief meaningful conversations about the harms of smoking
• know about the quitting support available

Effective pathways into specialist support should be in place, with feedback to the referring midwife. The elearning for healthcare platform also includes training modules on VBA and CO monitoring to support a smoke-free pregnancy. The training is free, but you need to register before you can log in.

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 smoke-free inpatient setting. You should encourage the use of e-cigarettes as one of the options available to support quitting or reduce harm.

7.2 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 the 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

7.3 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
• ensure that integrated care systems have prevention plans that set out the steps to be taken to effectively implement the NHS Long Term Plan commitments on tackling tobacco dependency
• commission evidenced-based stop smoking support that 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 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 and integrated care systems
• work to promote tobacco dependency treatment prominently in all commissioned healthcare services
• make sure to include the NHS Long Term Plan tobacco metrics in local performance monitoring systems

8. Indicators of tobacco’s effect on local populations

There are 3 indicators in the Public Health Outcomes Framework that relate to smoking:

1. Smoking status at time of delivery (indicator C06).
2. Smoking prevalence at age 15 (indicator C13a ‘Regular Smokers’ and indicator C13b ‘Occasional Smokers’).
3. Smoking prevalence in adults (18 and over) (current smokers) based on Annual Population Survey (APS) data (indicator C18).

The Local Tobacco Control Profiles for England provide data on 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 and over) 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
• smoking attributable deaths from cancer

9. Measuring local impact

As a health and care professional, there are many reasons why you should 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.

9.1 Everyday Interactions toolkit

The Royal Society for Public Health (RSPH) Everyday Interactions toolkit provides a quick, straightforward and easy way for health and care professionals to record and measure their public health impact in a uniform and comparable way.

RSPH also recommends the smoking and tobacco impact pathway for health and care professionals to record and measure actions undertaken as part of routine care.

9.2 CLeaR improvement model

CLeaR self-assessment is a continuous improvement model that supports local action to reduce tobacco use. CLeaR is an acronym for Challenging services, Leadership and Results. The model is designed to be used across local systems, 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 chance to compare 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
• addressing the impact of illicit tobacco
• action on niche tobacco products (for example, shisha and smokeless tobacco)

10. Further reading and resources

10.1 Advice for patients and the public

The Better Health quit smoking website provides information on free expert support, stop smoking aids, tools and practical steps on how to stop smoking. It includes links to a personal quit plan and a quit smoking app.

The NHS Live Well website also provides information, advice and support, with details of how to find local support to quit.

The pregnancy section of NHS Live Well and Tommy’s pregnancy hub website provide specific information, advice and support for smokers who are pregnant.

The NCSCT has produced a series of short information films on e-cigarettes, including a video on e-cigarette safety.

E-cigarette safety: the facts explained

In the UK Health Security Agency blog, Professor John Newton looked at some of the most common misconceptions about e-cigarettes and vaping and provided the facts.

10.2 Professional resources and tools

Health matters: stopping smoking – what works? focuses on the range of quit smoking routes that are available and the evidence for their effectiveness.

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 come up when giving advice to smokers.

Advice for services on making e-cigarettes available produced by the NCSCT, in consultation with OHID, aims to support English stop smoking services to make e-cigarettes (vapes) available to their clients.

The BMA report on e-cigarettes: balancing risks and opportunities discusses the regulation of e-cigarettes. It also argues for an approach that seeks to minimise their risks while maximising their potential to reduce the health burden associated with smoking.

The RCGP has published a position statement on e-cigarettes in partnership with Cancer Research UK, accompanied by a video that discusses the position statement.

RCGP position statement on e-cigarettes

Cancer Research UK’s E-cigarette hub provides information and access to resources for health professionals.

A collection of e-cigarettes and vaping policy, regulation and guidance has been published. In 2022, OHID will publish a comprehensive report on the up-to-date evidence, including on e-cigarette safety.

The Royal College of Physicians report Smoking and health 2021: a coming of age for tobacco control reviews the UK’s progress in reducing smoking and sets out comprehensive recommendations for action to achieve a smoke-free society. This includes NHS stop smoking treatment for all smokers on an opt-out basis.

The Smoking in Pregnancy Challenge Group has developed resources to support health professionals working to reduce smoking in pregnancy.

Stopping smoking in pregnancy: a briefing for maternity care providers gives expert, concise guidance on how to deliver VBA to pregnant women who smoke and how to carry out routine 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’s Brief guide for inspection teams: smokefree policies in mental health inpatient services notes that mental healthcare 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.

10.3 Resources to support commissioning

Stop smoking services: models of delivery 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 self-assessment is an evidence-based improvement model that supports local action to reduce the use of tobacco. CLeaR is an acronym for Challenging services, Leadership and Results. The model is designed to be used across local systems by local authorities, tobacco alliances and NHS partners.

The ASH Local Toolkit is a set of materials for local public health professionals involved in tobacco control. The materials are designed to be used with councillors and other stakeholders to help ensure that addressing 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.

10.4 NICE guidance and quality standards

NICE guideline Tobacco: preventing uptake, promoting quitting and treating dependence (NG209) includes recommendations on the advice that health and care professionals should provide to smokers on using e-cigarettes to quit.

NICE guideline Tobacco: preventing uptake, promoting quitting and treating dependence (NG209), published in November 2021, covers support to stop smoking for everyone aged 12 and over, and help to reduce people’s harm from smoking if they are not ready to stop in one go. It also covers ways to prevent children, young people and young adults aged 24 and under from taking up smoking. The guideline brings together and updates all NICE’s previous guidelines on using tobacco, including smokeless tobacco. It covers nicotine replacement therapy and e-cigarettes to help people stop smoking or reduce their harm from smoking.

This guideline replaces PH5, PH14, PH23, PH26, PH39, PH45, PH48 and NG92.

This guideline is the basis of QS43, QS92, QS17, QS82 and QS22.

NICE 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.

NICE Quality Standard – 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.

NICE Quality Standard – Smoking: reducing and preventing tobacco use (QS82) covers reducing tobacco use, including interventions to discourage people from taking up smoking, tobacco control strategies and smoke-free policies.

10.5 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
• deliver training and assessment programmes to stop smoking practitioners and other healthcare 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, through its elearning for healthcare programme, including:

1. The Supporting a Smokefree Pregnancy programme supports members of the midwifery team to provide VBA on smoking to their patients, including CO monitoring.
2. The Alcohol and Tobacco Brief Interventions programme provides healthcare professionals with the minimum level of knowledge and skill they need to identify risk. It also helps them to provide brief advice to patients who smoke or who are drinking at a level that could be harmful. And it supports staff training to meet requirements of the CQUIN scheme for screening and brief advice for alcohol and tobacco use in inpatient settings.

NHS England and NHS Improvement are currently developing new tobacco dependency training resources that are specifically tailored to the treatment pathways that are going to be implemented as part of the NHS Long Term Plan.

11. Good practice examples

11.1 CURE project

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.

11.2 Smoke-free Sheffield

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 case study ‘Smoke-free implementation in the Sheffield NHS Trust’.

11.3 Local maternity systems

The Smoking in Pregnancy Challenge Group has produced a resource for local maternity systems (LMS), which presents 3 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.