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Guided learning

Smoking cessation 2: targeting, engaging and supporting hard to reach groups

Clinical management of inpatients, pregnant women and young people who smoke, and the useful resources that are available to support them



Jennifer Percival, FETC, Dip Couns, HV Cert, RM, RGN, is RCN tobacco policy adviser and National Stop Smoking trainer.


Percival, J. (2009) Smoking cessation 2: targeting, engaging and supporting hard to reach groups. Nursing Times; 105: 39, early online publication.

This second in a two-part unit on smoking cessation discusses ways to engage and support hard to reach groups. Part 1 outlined the various options available to help smokers who want to quit, such as behavioural support and pharmacotherapy.

Keywords: Smoking cessation, Respiratory, Hard to reach groups

  • This article has been double-blind peer-reviewed.


Learning objectives

1. Know how to use a range of effective communication techniques to engage smokers traditionally considered hard to reach.

2. Understand how to initiate a discussion with hospital patients who smoke and women who smoke during pregnancy.



As smoking remains the single greatest cause of preventable illness and premature death in the UK (Department of Health, 2009), helping people to stop is an extremely productive use of nurses’ time. For example, helping someone stop smoking is the only intervention that can change the natural history of COPD or reduce the risk of lung cancer.

A survey in one hospital found that while 20% of inpatients smoked, less than a third were given smoking cessation advice, despite the hospital having a smoking cessation service (Warner et al, 2006). Another study in a district general hospital found that while there was high awareness of the local NHS Stop Smoking Service among healthcare professionals, only one in five staff had referred anyone to it (Elsheikh et al, 2006).

The evidence shows that providing help to stop smoking is the most clinically proven, cost effective, preventive action that healthcare professionals can undertake (West et al, 2000). Addressing smoking status, providing cessation advice and referral to NHS Stop Smoking Services needs to become embedded in routine practice as a matter of urgency (DH, 2009).

Hard to reach groups

People start smoking for various reasons and some will not have gone a day of their adult life without having a cigarette. Quitting is a huge challenge for many as they have to simultaneously stop their addiction, abandon comforting rituals and change their daily routine.

Some groups, such as pregnant women and young people, have been described as “hard to reach” because they seem less receptive to routine advice and reluctant to use NHS Stop Smoking Services.

When working with smokers who are difficult to engage, it is important to learn how to approach the subject non-judgementally to discover if they have any interest in quitting and provide tailored advice on services and treatments available. This approach would work well in hospital settings where inpatients may be much more open to health promotion advice, even if they have previously ignored it. For many people, being admitted to hospital provides the rationale for change (DH, 2009).

Effective communication techniques

Persuasion alone will not help people give up smoking. If an “advice-giving” approach is used, smokers can become defensive and give justifications or explanations for the reasons they smoke, especially if they think nurses’ prime objective is to get them to give up tobacco use.

Negative conversations such as these can leave healthcare professionals feeling demoralised and they do little to change smokers’ mindset. Changing the approach to one based on motivational interviewing techniques can help patients reflect on their choices and explore for themselves why they smoke and the benefits of stopping (Miller and Rollnick, 1991).

Nurses should try asking:

  • How long have you been a smoker?
  • Have you ever changed anything about the way you smoke? If so, why?
  • Has anyone ever told you to stop? If yes, why was that?
  • Are you aware of any changes to your health due to smoking?
  • Do you have any concerns about what may happen to you if you don’t stop?

Then paraphrase their responses without judgement. For example: “I can see it would be very hard for you to give up smoking at the moment because…” or “Right now continuing smoking is important to you, even though it increases your risk of returning to hospital.“ Summarising in this way can help people hear and reflect on their choices.  

If they are contented smokers, try asking: “Are you planning on being a lifelong smoker?” If the reply is no, ask: “What would have to happen to make you want to stop?” This type of discussion can plant the seeds of change and will help smokers think more realistically about the advantages and disadvantages of their habit.

If smokers are thinking about stopping:

  • Help them establish why they are undecided. Are the reasons they wish to continue more important than they acknowledge?
  • Check their knowledge about the health risks and personalise the benefits of stopping;
  • Explain the free NHS help available and how they can access it;
  • Encourage them to use nicotine replacement therapy (NRT), varenicline or bupropion, as appropriate, and check any misconceptions they may have about these.

Many people who give up smoking do so as a result of a health problem or crisis. The combination of nurses’ motivational support plus pharmacotherapy treatment increases smokers’ chances of successfully stopping by up to four times (DH, 2009).

Working with hospital and pre-operative patients

A recent Cochrane review (Rigotti et al, 2008) reported that delivering smoking cessation services to inpatients had a positive impact. It found that programmes started during hospital stays, and which included follow up support for at least one month after discharge, were effective. The DH (2009) recommends that if patients want to stop smoking following admission to hospital they should be given a brief intervention and referred for intensive support.

Another good opportunity for successful intervention is before surgery. Stopping smoking before an operation reduces the risk of wound infection, delayed wound healing and postoperative pulmonary and cardiac complications, and can mean a shorter stay in hospital. The DH (2009) recommends that all patients should receive brief intervention advice before surgery and be referred for more intensive support from their local NHS Stop Smoking Service. Those who decide not to stop smoking before surgery should be advised of the hospital’s smokefree policy and pharmacotherapy should be offered and provided through primary care (DH, 2009).

Managing withdrawal symptoms

Patients who smoke regularly before admission can suffer from withdrawal symptoms during a period of enforced abstinence. Using NRT while in hospital will help them manage these symptoms and may increase their confidence to continue abstinence after discharge.

The DH (2009) recommends all smokers’ nicotine dependency scores should be assessed following admission (planned and unplanned) and NRT provided as soon as possible to help them manage withdrawal symptoms.

Working with young people

There is little published evidence of the benefits of interventions focusing on cessation activity in adolescents. Only 3% of NHS Stop Smoking Service users who set a quit date were aged 18 or under (DH, 2009). Wider tobacco control activities such as the ban in public places, which stop smoking from being a normal activity, have been proven to reduce young people’s uptake of the habit (World Health Organization, 2008). The DH (2009) recommends services should be available for young people who want to stop smoking and these should link with healthy school programmes, health services on secondary school sites and other youth settings (Thomas and Perera, 2006).

Working with pregnant women

In pregnancy, smoking is the single most modifiable risk factor for adverse outcomes. It is estimated to contribute to 40% of all infant deaths, a 13% increased risk of premature birth and a 26% increased risk of intra-uterine growth restriction (Gardosi et al, 2005). Early intervention, that is, stopping smoking at three months’ gestation, significantly improves outcomes (West, 2002).

Teenage mothers are more likely than older women to have been smoking before becoming pregnant and are also less likely to stop during pregnancy. This group is therefore a DH priority for smoking cessation support. NICE (2008) guidance recommends that practitioners should discuss smoking status at the first contact with smokers who are either pregnant or planning a pregnancy. They should also provide information about the risks of smoking to the unborn child and the hazards of exposure to secondhand smoke. Many local NHS Stop Smoking Services employ specialist midwives to work with this group.

If pregnant women have no immediate plans to stop:

  • Ask: “What have you heard about the effects smoking has on the foetus?” This allows nurses to build on the information patients already have.
  • If a patient describes a benefit of smoking as having “a small baby”, ask: “Have you ever wondered how smoking can make a baby smaller?” Follow this with an explanation of how the presence of carbon monoxide from smoking reduces oxygen levels in the blood, which restricts the baby’s growth. In fact, the baby will not be “smaller” but weaker and less developed.

Throughout pregnancy

Nurses should encourage pregnant women to use local NHS Stop Smoking Services and the NHS Pregnancy Smoking Helpline by providing details on when, where and how to access them (Box 1). They should monitor smoking status and offer cessation advice, encouragement and support throughout the pregnancy and beyond.

For those worried about smoking during pregnancy (including partners, friends and family of pregnant women), the helpline offers specialist advice on stopping during pregnancy. Included in this service is a dedicated call-back programme, which offers periodic follow up calls during pregnancy and also post natally. Lines are open daily from 12 noon-9pm. This service is only available to smokers in England at the moment.

Nurses should discuss the risks and benefits of NRT with pregnant women who smoke, particularly those who do not wish to accept the offer of help from NHS Stop Smoking Services. The evidence on the effectiveness and safety of NRT in pregnancy is inconclusive (Coleman, 2007), although consensus opinion suggests that using it during pregnancy is likely to be safer than continuing to smoke. Practitioners should address any concerns pregnant women and their partners or families may have about stopping smoking.

New resources for use in pregnancy

The DH has just produced a toolkit for healthcare professionals who work with pregnant smokers and their partners. This contains a quick prompt guide encouraging staff to sensitively ask and record patients’ smoking status and to advise that quitting is the best thing they can do to improve their own and their baby’s health. The “Everything you need to help pregnant women to stop smoking” toolkit contains a helpful 3As guide (see part 1 of this unit), flash cards, posters and a Q&A booklet. To order your free toolkit call 0800 7316 427, or visit the Smokefree Resource Centre here.


Whether working in hospital or the community, healthcare professionals are in a prime position to encourage smokers to think about giving up and to provide appropriate information and help to quit.

No one is really “hard to reach” - the key is to ensure that the engagement methods used appeal to particular groups. Anyone can stop smoking once they invest time and thought in the issue, have enough information on ways to manage withdrawal symptoms, can plan ahead for difficult or unexpected situations and can see themselves living smokefree. Box 1 outlines contact numbers and online resources to give to patients, and Box 2 contains useful smoking cessation publications.

By applying the range of communication techniques outlined here, nurses can help any smoker regardless of age, socioeconomic status or gender, and explore their personal motivation to change. Providing a tailored brief intervention and describing the free expert help and NHS support available is never a waste of time.

Box 1. Stop smoking helplines and websites 


0800 169 0 169  

Northern Ireland

0800 85 85 85


0800 84 84 84


0800 085 2219


QUITLINE 0800 00 22 00

QUIT is the independent charity that helps smokers to stop. The QUITLINE is run by a trained counselling team, which offers support to anybody concerned about smoking, from smokers themselves to family or friends, and even teachers worried about pupils smoking.

NHS Pregnancy Smoking Helpline

0800 169 9 169                   


Box 2. Smoking cessation publications

Manual of Smoking Cessation: A Guide for Counsellors and Practitioners (Andy McEwen et al, 2006, Wiley-Blackwell).

This is a useful practical guide on how to conduct both brief and specialist cessation interventions with examples of how best to communicate information to patients. It gives the essential facts about smoking, the benefits of stopping and medications.

You Can Stop Smoking (Jennifer Percival, 2007, Virgin Books).

Written for smokers, it contains information on all aspects of quitting, self help exercises, tips from ex smokers, success plans and an insight to NHS services.

Motivational Interviewing in Health Care: Helping Patients Change Behavior (Applications of Motivational Interviewing)

(by Stephen Rollnick et al, 2008, Guilford Press).

Written for healthcare professionals, this book presents tools to enhance communication with patients and guide them in making choices to improve their health using the core skills of motivational interviewing. It shows how to incorporate this in any healthcare setting.


Online CPD

For the Portfolio Pages corresponding to this unit see the document above.

Portfolio Pages contain activities that correspond to the learning objectives in the unit. They are presented in a convenient format for you to print out or work through on screen and can be filed in your professional portfolio as evidence of your learning and professional development.

Click here for more Guided learning units.



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