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Developing a joined up approach to smoking cessation in primary and secondary care


A pioneering scheme aimed at improving smoking cessation rates has helped primary and secondary care nurses encourage more people to quit successfully


Anna Fairhurst, BSc, RN, is smoking cessation coordinator at Brighton and Hove Smoking Cessation Service.


Fairhurst A, (2010) Developing a joined up approach to smoking cessation. Nursing Times; 106: 37, 12-13.

Nurses are well placed to give patients help and advice on giving up smoking. This article describes how a groundbreaking nurse-led project in Brighton and Hove PCT has increased referrals to smoking cessation services and encouraged thousands of patients to quit. It also discusses the importance of healthcare professionals working together to support patients in their efforts to stop smoking and the need for training to ensure staff are engaged with the “quit” journey.

Keywords Smoking cessation, motivational assistance, joined up support

  • This article has been double-blind peer reviewed


Practice points

  • Nurses are ideally placed to advise patients about free and effective smoking cessation services, and to make a referral or treatment offer to every smoker.
  • Nurses can lead clinical teams to understand the importance of simple and brief interventions at every contact to improve outcomes.
  • Setting up simple systems to ensure referrals happen quickly and efficiently is essential to effective patient care.


Tobacco remains the single biggest cause of mortality and health inequality in the UK, killing more people than the next six leading causes of death combined (NHS Information Centre, 2009). Research shows smokers are up to four times more likely to quit successfully if they receive support from their local NHS Stop Smoking Service and take stop smoking medication, compared with relying on willpower alone. West (2010) found this support doubles the likelihood of long term quitting compared with behavioural support or medication alone.

However, interventions and referrals to local NHS Stop Smoking Services by healthcare professionals are lower than they could be. Recent research (West, 2010) showed that in primary care, more than half (57%) of smokers had received no advice to quit from their GP in the last 12 months.

By following simple steps, healthcare professionals can significantly increase the number of patients who are referred to local NHS Stop Smoking Services. They can do this by implementing the 30 second brief advice approach - known as ‘Ask, Advise and Act’ (Department of Health, 2009a) - and ensuring a fully integrated NHS smoking cessation and tobacco control framework, in which healthcare professionals in primary and secondary care settings work in a joined up manner.

Joined up support

In 2009, the Department of Health introduced two projects to ensure that patients receive joined up and consistent support across both primary and secondary care networks to improve the consistency and effectiveness of stop smoking interventions.  

The new primary care project, Stop smoking interventions in primary care, a systems based approach (DH, 2009b), is designed to help make stop smoking interventions by healthcare professionals more systematic (see Box 1). Pilot results have shown significant improvements, with those practices that have adopted this new system increasing their referrals to NHS services on average by 49% (Rotherham Primary Care Trust, 2008).

The Stop Smoking Interventions in Secondary Care guidance (DH, 2009c) was developed to give PCTs, local NHS Stop Smoking Services and acute trusts good practice guidance and practical tools for implementing a system-wide approach to smoking cessation for inpatients (see Box 2). One of the early pilot hospitals found that a month after the programme’s adoption, referrals to the local NHS Stop Smoking Service tripled among planned admission patients, with a commensurate increase in advice and help to stop being offered (DH, 2010).

Results can be even more impressive when these innovative approaches are

combined with a fully integrated network of healthcare professionals, including local stop smoking services, nurses, doctors and community pharmacists working as a team across a local area.

Tackling addiction

Brighton and Hove PCT has successfully followed a similar approach, including the development of an innovative referral network. The trust has seen a 37% increase in referrals since 2004. Last year 3,300 patients set a quit date, with over 2,000 successfully making it to their four week quit date, meeting the PCT’s ambitious targets.

Fifteen years ago, I set up a pioneering scheme to help hospital inpatients stop smoking. I was working within the chest unit at the Royal Sussex County Hospital where I regularly treated patients who were admitted to hospital with chronic obstructive airways disease (COAD) and chronic obstructive pulmonary disease (COPD). Those who were smokers quickly recovered from their symptoms during their stay as they were unable to smoke. However, within a few weeks we would see them readmitted with the same problems.

We began by asking all patients on admission if they wanted to stop smoking and provided those who did with weekly motivational support – helping them to cope with both the emotional and physical effects of their addiction. Our unit was relatively small, so I was able to ensure the in-house pharmacy team supported the project by offering NRT patches to inpatients, and giving them a four week supply on discharge. Evaluation at year 1 showed we had achieved a 50% quit rate from those we supported to stop smoking.

Following the success of this initial project, Royal Sussex County Hospital received ongoing funding by Health of the Nation and Our Healthier Nations initiatives. In 2000 this funding allowed the project to develop into a fully coordinated service. We also began training primary care healthcare professionals around the Brighton and Hove area, which led to a significant increase in the number of referrals and were able to fully replicate the project in Hastings and Eastbourne with similar results.

In 2003, the successes we had achieved - including signing up 40% of the GP surgeries in Brighton and Hove to run smoking cessation services - demonstrated to local NHS public health directors that smoking cessation clinics and comprehensive tobacco control care pathways (with integrated referral and intervention pathways) were vital to tackling broader health improvement issues. To address one aspect of this, Brighton and Hove PCT commissioned a local NHS Stop Smoking Service within the South Downs Health Trust, which I was appointed to co-ordinate. The role included managing a specialist team and training healthcare professionals, including GPs, practice nurses, secondary care nurses, doctors and local community pharmacists within the Brighton and Hove area.

Training to engage

We had seen from our previous work that engaging key healthcare professionals such as nurses, doctors and pharmacists in the quit journey meant that referrals increased and patients could receive support at any point they felt they might lapse - not just from NHS stop smoking advisers. Training is a cornerstone of engaging these partners to ensure the framework exists and makes the service a success.

The training includes one-to-one sessions; role play; group workshops on behavioural change techniques; and education on addiction and the different services that deal with specific requirements – such as medication.  

One of the key learning outcomes was that smoking should be dealt with as a clinical issue, which needs treating and referring to a specialised service in the same way as clinicians would normally refer conditions such as hypertension or high cholesterol. In the seven years of the project, we have signed up 90% of GP surgeries in the area and trained over 500 healthcare professionals to level 1 and level 2 smoking cessation training - including over 50% of the region’s pharmacy staff.

Having such a large number of qualified trainers, from a variety of entry points, ensures patients across Brighton and Hove have access to help in a variety of accessible locations and convenient times, and are receiving repeated and effective messages from trusted advisers about why and how to quit. These trained professionals also increase the number of referrals to our local NHS Stop Smoking Services who can offer more time and expertise for quitters. 

Nurses and doctors are able to offer a consistent intervention to smokers who are presenting with any issue, to have the maximum impact on their health and wellbeing.

Having all primary and secondary care healthcare professionals engaged in the framework and committed to the ‘Ask, Advise and Act’ protocol served as a solid foundation for receiving and quickly increasing referrals. In 2008, there were 2,882 referrals to our specialist local NHS Stop Smoking Services, a 371% increase from 2004 - over twice as much as a comparable sized PCT.

Motivation is essential

Evidence shows smokers are four times more likely to succeed in quitting if they receive behavioural support and medication from trained advisers within the local NHS Stop Smoking Services (West, 2010). By offering treatment based on clinical evidence, motivation and support, by boosting patients’ self esteem and providing the tools needed to support an effective quit attempt, we give quitters the best possible opportunity to succeed, every time they make a quit attempt (Fiore et al, 2000).

This is equally important in engaging fellow healthcare professionals to work in an integrated way. If they feel supported, understand the full process and objectives of the project, and have close working relationships where they can quickly access guidance and pass on referrals for specialist support, they will be motivated to work together. A cohesive framework will ensure that quitters receive consistent treatment, and this in turn ensures we get the best possible results - both in terms of patients’ health but also great referral and outcome figures.


Box 1. A systematic approach to stop smoking interventions in primary care

Stop smoking interventions in primary care, a systems based approach has been developed by the Department of Health to ensure that stop smoking interventions by healthcare professionals are routine and systematic, providing a tailored and consistent approach to patient referral. This approach recognises smoking as a key clinical issue requiring treatment or referral to a specialist, joining standard issues such as hypertension or high cholesterol.

The system ensures that basic advice on stopping smoking is offered to all smokers, which doubles the likelihood of a quit attempt. Practices that have this systems-based approach in place are expected to see improved quit rates in their patients. 

The supportive delivery system consists of 10 components, including senior level commitment, written protocols, training and NHS Stop Smoking information, to ensure that successful smoking advice becomes routine. It is also designed to establish a practice environment that demonstrates commitment to support all patients in stopping smoking.

The system offers the most effective advice in the limited time that is available, based on a tiered approach that establishes three levels of intervention:

  • Brief advice for all smokers. This is based on the ‘3As’ (Ask, Advise, Act) guidance issued in January 2009, and allows healthcare professionals to deliver advice to smokers in just 30 seconds;
  • A resource-intense intervention (5-10 minutes) for smokers who already have, or who are at high risk of developing, a smoking-related disease;
  • A highly resource-intense intervention for patients who are already motivated to quit.

For more information about the new primary healthcare project contact your local NHS Stop Smoking Service.

Source: DH, 2009b


Box 2. Stop smoking interventions in secondary care

In secondary care, approximately 1.4 million annual NHS hospital admissions have a primary diagnosis of a disease related to smoking, which means that there is enormous scope to increase referrals and improve quality of care for both planned and unplanned admissions.

The NHS is piloting a secondary care approach to smoking interventions in around 70 trusts. The ‘Stop Smoking Interventions in Secondary Care’ guidance was developed in order to give PCTs, local NHS Stop Smoking Services, and acute trusts good practice guidance and practical tools for implementing a system-wide approach to smoking cessation for inpatients including:

  • Embedding assessment of smoking status and offers of support into every clinical contact between healthcare professional and smoker;
  • Improving referral rates to the most effective forms of support (namely local NHS Stop Smoking Services plus medication), which is aligned to the brief advice approach, ‘Ask, Advise and Act’;
  • Offering clinical support to smokers who are in hospital and experiencing forced abstinence;
  • Monitoring the effects of these activities.

Source: DH, 2009c

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Readers' comments (2)

  • Referrals can only occur if the patient is willing. Until a person is wanting to and ready to quit smoking there is very little we can do, apart from advising on the dangers.

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  • I agree with the above. However, a persons 'willingness' to quit should not deter us from using opportunities for discussion. A recent patient of mine had been admitted to an elective, orthopaedic ward for surgery. She had been advised on numerous occasions to quit, but was unsuccessful in her attempts. On admission, she was anxious and fearful of the withdrawals given the realisation that she would on bed rest for 24/36hours after the procedure, and she was also resentful of the health care practitioners given her state of cognitive dissonance. The wards usual approach to patients such as these is to inform of the non-smoking policy, offer patches and tell them they 'should quit'. Given that I was learning smoking cessation, I used the period of abstinence as an opportunity to build her self-efficacy and give her insight into the possibility of living smoke-free. Whilst the intention was to support her through withdrawals and enhance coping strategies, through intensive support and the correct medication, the patient was discharged smoke-free (with a community support package, strategies that both herself and husband could employ, and a great deal of confidence).

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