Delivery of effective smoking cessation interventions to smokers requires healthcare professionals to have appropriate training and skills, says Jennifer Percival

NICE Public Health Guideline 26 on the how to stop smoking in pregnancy and following childbirth has been awarded the NHS Evidence Accreditation Mark. This Mark identifies the most robustly produced guidance available. See evidence.nhs.uk/accreditation for further details.

Smoking remains a massive public health problem: findings from the Smoking Toolkit Study (a continuous series of monthly surveys sampling people in England aged over 16 years) shows that there has been little change in smoking prevalence since 2008—in 2010, 21.9% of the population were smokers. 1 Disappointingly, the proportion of smokers making a quit attempt has declined from 42.5% in 2007 to 35.9% in 2010. 1 As one in six of all UK annual deaths can be attributed to smoking, 2 it is important that primary care healthcare professionals continue to address this public health challenge. Providing smoking cessation advice remains a highly cost-effective intervention. 3

Guidance on smoking cessation

National guidance on smoking cessation is based on strong evidence for the use of intensive behavioural support plus pharmacotherapy. There are four pieces of guidance on smoking cessation relevant to primary care:

  • NICE—Brief interventions and referral for smoking cessation in primary care and other settings 3
  • NICE—How to stop smoking in pregnancy and following childbirth 4
  • NICE—Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities 4
  • Department of Health (DH)—NHS stop smoking services: service and monitoring guidance 2010/11. 6

Brief interventions

Brief interventions to stop smoking provide a quick, easy and potentially life-changing opportunity for many smokers. In particular NICE recommends providing: 3

  • simple advice about stopping
  • an assessment of motivation to stop
  • cessation-orientated pharmacotherapy or referral to NHS stop smoking services.

Smoking cessation in postnatal and antenatal women

In 2010, NICE published guidance on smoking cessation during and following pregnancy. 4 The key recommendations were to:

  • monitor women's smoking status throughout pregnancy by routine carbon monoxide measurement
  • offer smoking cessation advice and referral to a specialist service
  • provide encouragement and support to quit smoking throughout the pregnancy and beyond.

Although routine testing for carbon monoxide has met with some resistance, it is slowly being introduced at the booking appointment. This allows maternity staff to identify which women need advice and support, as under-reporting is unfortunately a common occurrence. General practice staff can assist by following up on pregnant women who are referred for help to quit, as some may not attend and could be more open to support from practice staff.

Stop smoking services

Guidance from both the DH and NICE emphasise the importance of very brief advice. The DH notes that advice and/or counselling from a physician or nurse can significantly increase the likelihood of quitting, 6 with NICE recommending the provision of advice based on the need to quit, assessment of motivation, and offer of stop smoking medication and referral to a local service. 3


Supporting smokers who want to quit

The Smoking Toolkit Study showed that over 40% of all current smokers really want to quit. 1 As tobacco use is an addiction, most users need professional help and support and primary care staff are well placed to provide this. However, of all smokers in 2010, only a minority recalled having a discussion with their GP in the past 12 months, almost 60% received no mention of smoking or had no interaction with their GP, and only 26% recalled having been offered a prescription or advice to see a specialist. 1

Simply advising smokers to stop has not been demonstrated to be effective, as individuals receiving this advice are no more likely to quit than those who received no advice or who have not visited their GP! However, offering a prescription and a referral for behavioural support, for example, from the practice specialist or NHS Stop Smoking Service is associated with a significant increase in quit attempts. 1

'Very brief advice'

Very brief advice (VBA) is a simple piece of advice that satisfies quality and outcomes framework criteria, and is designed to be used opportunistically in less than 30 seconds in almost any consultation with a smoker (see Figure 1).7 There are three elements to VBA:

  • ASK—establishing and recording smoking status
  • ADVISE—advising on the best ways of stopping
  • ACT—offering help.

A new online training module has been launched recently, demonstrating how easy it is to deliver VBA (www.ncsct.co.uk/VBA).

Figure 1: Very brief advice: The ACT, ADVISE, ASK (AAA) model7
Reproduced with permission from NHS Centre for Smoking Cessation and Training

NHS Centre for Smoking Cessation and Training

The NHS Centre for Smoking Cessation and Training (NCSCT) was set up to improve the overall quality of behavioural support and treatment provided to people who wish to stop smoking. 7 The exact components of 'behavioural support', were unknown until the NCSCT developed the evidence on what the vital parts of helping smokers to quit actually are (see Box 1). 8,9

The NCSCT is a key resource in training healthcare professionals to become proficient at supporting smokers to quit. The NCSCT has an online training module (www.ncsct.co.uk), which provides information on the competences, knowledge, and skills required to deliver effective smoking cessation interventions. These competences are described in the training standard. 9 The NCSCT Training and Assessment Programme gives practitioners the opportunity to learn or improve these skills through film clips, 'test yourself' questions, and links to supplementary information; certification is given on completion. The components of a structured individual face-to-face smoking cessation intervention are described in the standard treatment programme. 10 The NCSCT also runs face-to-face training on 'skills-based' competencies, and to date over 700 practitioners have attended these courses, many of whom work in primary care settings.

The key areas for behavioural support for people wishing to stop smoking are listed in Box 2.

'Not-a-puff' rule

The NCSCT established the importance of asking people who set a quit date to commit to not having a single puff on a cigarette from that day onwards, as between 75% and 95% of quitters who have a single cigarette following their quit date, resume regular smoking. 11 Taking a single puff reminds the smokers' mind and body of what they have missed and increases their withdrawal symptoms. By asking patients to adhere to this strict rule and committing themselves to it aloud, healthcare professionals are removing any ambiguity about what they want to achieve.

Box 1: Core behavioural competences for healthcare professionals helping smokers to quit9
  • Describing treatment programme
  • Building rapport
  • Describing behavioural support
  • Facilitating and advising on social support
  • Describing stop smoking medication
  • Assisting clients to set a quit date
  • Enhancing motivation and self-advocacy
  • Emphasising importance of 'not a single puff'
  • Securing commitment to the 'not a puff' rule
  • Helping patients to cope with barriers, cues, and triggers
  • Assessing experience of medication
  • Advising on and adjusting medication usage
  • Using carbon monoxide measurements
  • Dealing with discrepancies between self-reported and carbon monoxide-validated smoking behaviour
  • Dealing with lapses
  • Assessing commitment, ability, and readiness to quit.

Reproduced with permission from NHS Centre for Smoking Cessation and Training


Barriers to success

Many surgeries have a resident stop smoking practitioner who is trained to provide patient support. It is important that this individual is allowed sufficient time to support smokers fully. The DH service and monitoring guidance recommends a 20–30 minute session for the pre-quit assessment followed by at least 10 shorter sessions (around 10 minutes) over a 12-week period. 6 Some practices may find this hard to achieve, but it is a good investment of staff time in light of the evidence on the effectiveness of medication plus behavioural support.

Conclusion

It is vital not to lose sight of the importance of addressing tobacco
use—one of the biggest issues in healthcare—especially when responsibility for public health is being restructured. Helping people to stop smoking is a time-consuming process. Many smokers take months or even years to get into the right frame of mind to quit and most will make several attempts before they stop for good. This is quite normal and should not be considered a waste of staff time. By continuing to give every smoker clear advice to stop, offering them treatment for withdrawal symptoms, and applying NCSCT advice on evidence-based competences, primary care staff can increase the number of quit attempts made and quadruple a smoker's chance of success.

Box 2: NCSCT pre-quit and quit-date checklist10

Pre-quit assessment

  • Assess current readiness and ability to quit
  • Inform the client about the treatment programme
  • Assess current smoking
  • Assess past quit attempts
  • Explain how tobacco dependence develops and assess nicotine dependence
  • Explain and conduct carbon monoxide monitoring
  • Explain the importance of abrupt cessation and the 'not-a-puff' rule
  • Inform the client about withdrawal symptoms
  • Discuss stop smoking medication
  • Set the Quit Date
  • Prompt a commitment from the client
  • Discuss preparations and provide a summary.

Quit date

  • Confirm readiness and ability to quit
  • Confirm that the client has a sufficient supply of medication and discuss expectations of medication
  • Discuss withdrawal symptoms and cravings/urges to smoke and how to deal with them
  • Advise on changing routine
  • Discuss how to address the issue of the client's smoking contacts and how the client can obtain support during their quit attempt
  • Address any potential high-risk situations in the coming week
  • Conduct carbon monoxide monitoring
  • Confirm the importance of abrupt cessation
  • Prompt a commitment from the client
  • Discuss plans and provide a summary.

NCSCT=NHS Centre for Smoking Cessation and Training

Reproduced with permission from NHS Centre for Smoking Cessation and Training


  • Commissioners should work with local public health professionals to define a local strategy for smoking cessation that is responsive to the local population dynamics
  • CCG leads should work with those responsible for the setting of such a strategy to ensure effective delivery of stop smoking interventions for smokers in their local area from 2013 onwards (when public health becomes the responsibility of local authorities based on current legislation)
  • Smoking cessation should be a high priority for future Health and Wellbeing Boards when setting Local Health and Wellbeing Strategies, and CCGs should ensure that they are appropriately represented on these
  • Clarity should be sought now over the future roles and employment setting for smoking cessation staff who currently work in public heath (e.g. CCG, Local Authority, or other).

CCG=clinical commissioning group

  1. West R, Fidler J. Smoking and smoking cessation in England 2010: findings from the smoking toolkit study. 2011. Available at: www.smokinginengland.info/
  2. The NHS Information Centre website. One in six deaths caused by smoking. www.ic.nhs.uk/news-and-events/press-office/press-releases/archived-press-releases/april-2006--march-2007/one-in-six-deaths-caused-by-smoking (accessed 2 March 2012).
  3. National Institute for Health and Care Excellence. Brief interventions and referrals for smoking cessation in primary care and other settings. Public Health Guidance 1. London: NICE, 2006. Available at: www.nice.org.uk/guidance/PH1
  4. National Institute for Health and Care Excellence. How to stop smoking in pregnancy and following childbirth. Public Health Guidance 26. London: NICE, 2010. Available at: www.nice.org.uk/guidance/PH26nhs_accreditation
  5. National Institute for Health and Care Excellence. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. Public Health Guidance 10. London: NICE, 2008. Available at: www.nice.org.uk/guidance/PH10 nhs_accreditation
  6. Department of Health. NHS stop smoking services: service and monitoring guidance 2010/11. London: DH, 2009. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_109696
  7. NHS Centre for Smoking Cessation and Training (NCSCT) website. www.ncsct.co.uk (accessed 15 February 2012).
  8. Michie S, Churchill S, West R. Identifying evidence-based competences required to deliver behavioral support for smoking cessation. Ann Behav Med 2011; 41 (1): 59–70.
  9. NHS Centre for Smoking Cessation and Training. NCSCT training standard: learning outcomes for training stop smoking practitioners. NCSCT, 2010. Available at: www.ncsct.co.uk/Content/FileManager/documents/NCSCT_Training_Standard.pdf
  10. NHS Centre for Smoking Cessation and Training. Standard treatment programme. NCSCT, 2010. Available at: www.ncsct.co.uk/Content/FileManager/documents/NCSCT_STP_ed2.pdf
  11. Brandon T, Tiffany S, Obremski K, Baker T. Postcessation cigarette use: the process of relapse. Addict Behav 1990; 15 (2): 105–114.G