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Smoking cessation

How to advise and refer inpatients who smoke

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Inpatients often feel motivated to stop smoking, but are not always referred for support. A very brief advice and electronic referral system aimed to remedy this

In this article…

  • Why inpatients are primed to receive stop-smoking advice
  • How nurses can offer very brief stop-smoking advice
  • Why more referrals to stop-smoking services are needed
  • 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


Liz Hughes is smoking cessation delivery manager; Melanie McIlvar is director, National Centre for Smoking Cessation and Training, Andy McEwen is senior research nurse, University College London.


Hughes L et al (2013) How to advise and refer inpatients who smoke. Nursing Times; 109: 1/2, 14-18.

Patients who smoke are more likely to experience postoperative complications than non-smokers and up to one-third of all hospital patients are estimated to be smokers.

Inpatients are receptive to an offer of stop-smoking support but are not always referred to stop-smoking services.

A pilot of a acute care referral system trained staff to deliver very brief advice on smoking via a short online training module, and provided a streamlined electronic referral system to local NHS stop-smoking services.

The three-month pilot resulted in a 600% increase in referrals. Nursing staff felt that the system was simple and effective, and that patients had benefited.

  • 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

Smoking increases the risk of postoperative complications and increases recovery time (Møller et al, 2002). Smokers are more likely to experience slower wound healing, which can result in further surgery, a longer hospital stay and/or increased costs to the health service (Wong et al, 2012).

Multiple health problems, which can be linked directly to smoking, frequently lead to periods of hospitalisation (Department of Health, 2009). In 2009-10 there were 1.5 million hospital admissions for adults aged 35 and over with a primary diagnosis of a disease caused by smoking - approximately 4,100 admissions per day (NHS Information Centre, 2012). It was estimated that smoking cost the NHS £5.2bn in 2005-06, 5.5% of total healthcare costs (Allender et al, 2009).

While there is no standard smoking prevalence measure of hospital patients, data collected by the National Centre for Smoking Cessation and Training indicates smoking prevalence among hospital patients to be 31% (NCSCT, 2012), well above the national average of 21% (Office for National Statistics, 2011).

Intervention in acute care

Patients are more receptive to an offer of stop-smoking support while in hospital. They often experience a period of heightened motivation to stop smoking following admission, plus a reduced opportunity to smoke, which can be an excellent time to offer what is termed “very brief advice” (DH, 2009).

Very brief advice (VBA) involves:

  • Establishing smoking status (Ask);
  • Informing the patient that the best way to quit is with a combination of trained support and medication (Advise);
  • Referring smokers who want to quit to their local stop smoking service (Act).

A Cochrane review has highlighted the appropriateness of offering VBA to all hospitalised smokers, regardless of their admitting diagnosis (Rigotti et al, 2007). It is also the single most cost-effective and clinically proven preventive action a health professional can take (Anczak and Nogler, 2003).

This approach has been advocated in the DH’s Make Every Contact Count initiative (DH, 2012). Patients identified as smokers and referred to their local stop-smoking service, who then go on to make a quit attempt, are four times more likely to quit successfully than if they had quit “cold turkey” (West, 2012).

Although stop-smoking support in acute care has developed significantly over recent years, it remains varied, ranging from no activity in some acute trusts to established systems in others. A standardised method of identifying and referring hospital patients to local stop- smoking services does not currently exist.

A survey of those delivering stop-smoking support in acute settings, carried out in March 2011, showed that nearly 90% of respondents believed that not having a robust electronic referral system from the hospital was limiting current activity and that such a system would be of value (NCSCT, 2011).

To support development within this area, the DH commissioned the NCSCT to test a streamlined, systematic and robust referral system in one acute trust.

NSCST Stop Smoking Referral System

The NCSCT Stop Smoking Referral System is a whole-hospital approach to stop-smoking support for patients. It focuses on supporting staff to ask and record smoking status for every patient, to deliver 30-second VBA (Ask, Advise, Act) and to refer patients to stop-smoking services. An electronic referral system is incorporated within the existing hospital IT system and refers patients to their local stop-smoking service.

The system also includes an evidence-based online training programme that provides the necessary knowledge required to deliver VBA in hospitals. It includes local information, to increase relevance for participating staff, and an assessment to ensure that key learning points have been understood.

The NCSCT Stop Smoking Referral System was piloted in the Queen Alexandra Hospital in Portsmouth, part of the Portsmouth Hospitals Trust, for three months (November 2011 to February 2012).

Staff training

The VBA training was available online, so it was easily and readily accessible for frontline staff. Training activity could be measured and, because it was hosted on the NCSCT server, it did not place an IT burden on the hospital.

A total of 282 hospital staff from the pilot departments (trauma and orthopaedics, respiratory and maxillofacial outpatients, respiratory, cardiology and maternity inpatients, and general surgery/preoperative assessment clinics) went through the VBA training module between September 2011 and February 2012.

This represented a 415% increase in the number of staff trained to give very brief advice compared with the number trained in the two years before the pilot started. A total of 119 nurses completed the training, along with 49 doctors, 47 healthcare assistants, 44 midwives, 27 administrative staff and three pharmacists.

Staff said the online training was straightforward, quick and easy to access.

“It was very easy to access, it worked as it said it was going to… and because it was as short as it said it was, we were able to go round everybody in our department and say ‘come on guys you can do this’.” (Nurse specialist)

The electronic referral system

Once staff had delivered VBA to patients and recorded their smoking status (smoker, ex-smoker, never smoker), where patients were interested in quitting, an indication was made in their notes that a referral for stop-smoking support was needed. A sticker was then placed on the patients’ notes (Fig 1).

On seeing this, the ward administrator indicated in the patient’s electronic notes that a referral should be sent to the referral management system (RMS), hosted on a server within the NHS N3 network.

The RMS, developed by the NCSCT, sorts patients by their postcode and refers them on to their local stop-smoking service or support, anywhere in England.


In total, 187 referrals were made electronically from the pilot departments via the RMS on to local stop smoking support services over the pilot period. An additional 143 referrals were made using existing paper referral forms from departments wishing to become involved in the pilot, while they waited for the RMS to become available on their system.

A total of 330 were received - a 602% increase in referrals overall. Fig 2 shows how many electronic and paper referrals were received and how these compared with 2010-11.

Interviews with frontline staff

Staff felt that it was beneficial to have a system in place to identify smokers, document smoking status and refer them on to support.

“If this works, and this makes it easy and it sort of means that more people are stopping smoking, I would like this to continue forever because I think it’s fantastic.” (Nurse specialist)

Staff reported that patients did not mind being approached about their smoking.

“Initially you feel a bit hesitant about asking patients. But if you realise that they’re coming to the hospital expecting to be asked that question… it gives you a bit more confidence to go ahead with that…

I think, just having a scheme that backs you up makes you more confident in approaching the patient… And in fact also that you have somewhere you can refer them to, so, and you’re not just advising… giving them advice, you can actually put them in touch with the right people.” (Lead nurse)

In addition, staff indicated that they felt the pilot was beneficial to their patients.

“I think the fact that they are referred via a central system that can be monitored and they can be directed to the appropriate support, the fact that the project is there offering them support… has to be advantageous to the patient.” (Nurse specialist)

It was also reported that patients responded positively to the offer of a referral and were grateful for the offer of support. This counteracted the concerns some staff had regarding how appropriate it was to discuss smoking with patients.

“I think they’re open minded. I think they’re grateful that help is available to them for helping to give up smoking.” (Nurse specialist)

Operational staff generally indicated that the pilot did not have a detrimental impact on their day-to-day role. It was incorporated into everyday practice, despite initial concerns about how long the intervention and referral would take, and its impact in an already time-pressured environment.

“It’s been quite a few weeks… or months that we’ve been doing it; and it’s just sort of been incorporated into everyday life now.” (Nurse specialist)


Piloting the NCSCT Stop Smoking Referral System at the Queen Alexandra Hospital resulted in a 415% increase in the number of staff trained to deliver very brief stop-smoking advice, and a 600% increase in referrals to local stop-smoking services. There was excellent staff engagement throughout the hospital, resulting in increased knowledge of how to give VBA and refer patients for stop-smoking support.

The pilot had a systematic impact on staff behaviour and staff recognised its benefits for patients. Concerns that staff had about the amount of time the intervention would take, and how receptive patients would be to discussing smoking, were counteracted by the simplicity of the process, the fact that patients expected to be asked about smoking, and how positively patients responded to the offer of support and referral.

The online training was positively received and was shown to be effective and efficient, as it did not burden the pilot departments with the requirement to release staff for face-to-face training.

The RMS has proved to be an efficient and effective method of referring patients on to their local stop-smoking service. It provides an auditable and accountable system that should be rolled out more widely.


Evaluation of the pilot has resulted in the following recommendations for acute trusts:

  • There needs to be a cultural change within trusts, starting with routine delivery of VBA and referral of patients to stop-smoking support, embedded within the day-to-day practice of frontline staff;
  • Referrals from acute settings to stop-smoking services should be made electronically, which ensures patients are contacted far more quickly than via paper referral methods. This also provides an auditable system that can support measurement of performance, for example against a smoking-related Commissioning for Quality and Innovation (CQUIN) indicator;
  • Frontline hospital staff should be trained online to give VBA to all patients, as it is an efficient and measurable training method;
  • The trust IT department is a key stakeholder, as changes need to be made to the internal IT system. Ideally, all patient electronic data capture methods for hospitals would include a smoking status field;
  • Nicotine replacement therapy and other stop-smoking medicines should be available on hospital formularies, with information provided to both staff and patients on how to use them effectively, even if only for temporary abstinence;
  • Research needs to be commissioned to look at the take-up of stop-smoking services and quit rates of patients referred from acute care. 

Acknowledgement: The authors wish to thank Queen Alexandra Hospital, Portsmouth Hospitals Trust, NHS Portsmouth, Pompey Quit (Solent NHS Trust Stop Smoking Service), NHS Hampshire, Quit 4 Life (Southern Health Foundation Trust), North 51, and Rachael Murray, Nottingham University.

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