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NICE guidance

Hospitals’ duty of care in smoking cessation

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The National Institute for Health and Care Excellence says hospitals have a duty of care to help all patients who smoke to stop and has issued guidance on this

In this article…

  • The effects of smoking on public health
  • Summary of NICE’s smoking cessation guidance
  • Explanation of the national referral system



Liz Gilbert is smoking cessation delivery manager and a member of the National Institute for Health and Care Excellence guideline development group; Melanie McIlvar is operations director; both at National Centre for Smoking Cessation and Training.



Gilbert L, McIlvar M (2014) Hospitals’ duty of care in smoking cessation. Nursing Times; 110: 4, 22-24.

Smoking has huge financial and health implications, yet there is no standardised method of identifying and referring hospital patients to local stop smoking services in England.

This article summarises new National Institute for Health and Care Excellence guidance on supporting people to stop smoking in acute, maternity and mental health services, and also explains the national referral system.

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page



5 key points

  1. Smoking carries huge financial and health costs
  2. Patients are often more motivated to stop smoking and open to cessation support while in hospital
  3. The guidance aims to help practitioners to identify patients who smoke and offer stop-smoking support routinely
  4. People with serious mental illnesses are more likely to smoke than others but are less likely to be offered help to quit
  5. A national referral system pilot resulted in a 600% increase in patient referrals to stop-smoking support


The National Institute for Health and Care Excellence has published new public health smoking cessation guidance specifically for secondary care (NICE, 2013).

The new guideline sets out how to support people using acute, maternity and mental health services to stop smoking, and recommends actions health professionals can take. These include promoting cessation before planned admissions, having stop-smoking interventions immediately available, offering behavioural support after admission to hospital and making all NHS secondary care settings completely smoke free.

NICE guidance

A number of diseases are caused by smoking including heart disease, cancers and respiratory diseases, all of which have financial implications for the NHS and wider society. Smoking is responsible for over 460,000 hospital admissions in

England each year, and is the biggest avoidable cause of inequalities in health. Smoking in pregnancy causes up to 5,000 miscarriages and stillbirths each year, and increases the risk of premature birth and low birthweight. In children, secondhand smoke causes sudden infant death syndrome and middle ear disease, and exacerbates asthma.

A Cochrane review confirmed the positive impact of implementing stop-smoking services for inpatients. This systematic review found that stop-smoking programmes aimed at inpatients with support for at least one month after discharge are effective, regardless of admitting diagnosis (Rigotti et al, 2008).

Patients who remain smoke free during a stay in hospital will heal more quickly and are less likely to be readmitted. In addition, patients are more receptive to smoking-cessation support while in hospital, and are often more motivated to stop smoking following admission (Department of Health, 2009).

Aims of the guidance

This guideline gives specific recommendations on how to initiate and maintain a cultural change in an organisation. It states that NHS hospitals should help all patients who smoke to stop both before and during a hospital stay, as well as ideally remaining smoke free after their hospital treatment.

The overall aims of the guideline are to ensure patients who smoke are identified, that offering support to stop smoking is part of routine practice, and that for clinical staff to feel this is part of their duty of care. Evidence suggests that patients already expect this care, with 95% of patients expecting to be asked if they smoke by a health professional (Slama et al, 1989).

The guideline aims to make it unacceptable to smoke anywhere in NHS hospitals or grounds, encouraging the health service to lead by example. It states that NHS hospitals should provide everyone with verbal and written information about the hospital’s smoke-free policy before their appointment, procedure or hospital stay, and that this should include the short and long-term benefits of stopping smoking and details of the support available.

A clinical or medical director should be assigned as the lead on stop-smoking support and smoke-free policy for the organisation. This lead person should promote stop-smoking support for patients and staff and ban staff-facilitated patient smoking breaks and the sale of tobacco products in secondary care settings. They should also ensure smoke-free plans include removing shelters or other designated outdoor smoking areas, and ensuring staff, contractor or volunteer contracts do not allow smoking during working hours or when in uniform or on hospital business.

The guideline states that NHS hospitals should provide intensive support for people using secondary care services, and discussions about past and current smoking behaviour should be included in a personal stop-smoking plan (see Box 1). This should also include providing immediate access to licensed nicotine-containing products, such as nicotine replacement therapy patches or gum, or other pharmacotherapies.

The guidance also notes that patients’ healthcare providers or prescribers need to be alerted to changes in smoking behaviour, as doses of other medications may need adjusting.

Mental health

Smoking is especially common among people with mental health problems; while one in five of the general population smokes, this figure rises to one in three among people with longstanding mental illness and to 70% of people in psychiatric units. The guideline highlights and emphasises how people with mental health problems who smoke can successfully stop when provided with the right support.

The law states that people cannot smoke inside enclosed or mostly enclosed workplaces, but in mental health units patients are often allowed to smoke in hospital grounds.

Most of the reduction in life expectancy among people with serious mental illness is attributed to smoking. It also increases the doses required of psychotropic drugs, costing an estimated £40m extra per year in the UK.

Research shows that people with mental health problems want to stop smoking as much as those without and are able to stop when offered evidence-based support (Royal College of Physicians and Royal College of Psychiatrists, 2013; Siru et al, 2009; Jochelson and Majrowski, 2006). However, they are less likely to be offered support, with smoke-free policies commonly not well adopted by mental health staff.

Carers and visitors

Secondhand smoke is also highlighted in the guideline, as is the need to provide relatives, carers, friends and other visitors with information about the risks of smoking and secondhand smoke.

This should include advice not to smoke near the patient, pregnant women or children, and not in the house or car. It is important that visitors know smoking is not allowed on the premises and that it is made clear where people can buy nicotine replacement therapies on site.

The national referral system

Offering advice and support to stop smoking is the single most cost-effective and clinically proven preventive action a health professional can take. It is important to keep giving advice at every opportunity, as smokers may take several attempts to stop smoking successfully (Fu et al, 2006).

Patients who are referred to a local stop- smoking service are up to four times more likely to quit (Smoking Toolkit Study, 2001). However, referrals are low and there are a great number of missed opportunities with this highly captive audience (National Centre for Smoking Cessation and Training, 2012).

The national referral system (NRS) developed by the NCSCT has been hugely successful in initiating cultural change within acute trusts. In the initial pilot in 2011, there was a 600% increase in patient referrals to stop-smoking support, and a 400% increase in staff trained to give advice and offer support to patients. The NRS will be implemented in at least 17 acute trusts in England by the end of March 2014.

The system offers a comprehensive approach to supporting patients to stop smoking, by enabling staff to record patients’ smoking status within the electronic patient record, and to make a referral by simply ticking a box. The patient details are then sent securely to the NRS and automatically received by the patient’s local stop-smoking support provider. The system also offers online training on how to give advice to patients and how to make a referral to stop-smoking support.


Stop-smoking support in secondary care settings has developed significantly over recent years. However, this ranges a great deal, from no activity in some acute trusts to established systems and activity in others.

There is currently no standardised method of identifying and referring hospital patients to local stop-smoking services in England. It is hoped that this new guideline will encourage NHS hospitals and other care settings to establish effective systems to offer the best possible support to help patients to stop smoking before, during and after they visit a secondary care setting.


● The full guideline is availble at: Smoking Cessation: Acute, Maternity and Mental Health Services

● If you would like any additional information on the National Referral System or would like to discuss the guidance, contact Liz Gilbert, email:


  • 1 Comment

Readers' comments (1)

  • NICE guidance is all about supporting people to quit which is fine for those who want to. But what about people who don't want to quit -be they patients, visitors or carers? How will their choice be supported?
    I wrote the attached in an attempt to draw attention to the way in which their rights and choices are being overlooked and/or denied.

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