Originally published: January 2019

Key learning points

  • Smoking is the most preventable cause of death and ill health in England
  • It is difficult for people to give up smoking and they need expert help to succeed
  • Support is available through the NHS and the best way to stop smoking is a combination of specialist help plus licensed medication
  • Evidence suggests e-cigarettes are less harmful than smoking but are not risk-free


Smoking is the single most preventable cause of death and ill health in England and half of all smokers die prematurely because of smoking.1 Smoking disproportionately affects the poorest members of society, owing to differences in culture and lifestyle.2 It is one of the main reasons for health inequalities and a cause of great concern.

Most people start using tobacco as children and despite frequent attempts to quit, remain lifelong smokers as a result of the highly addictive nature of nicotine.3 Smoking is a long-term condition, classified by the Royal College of Physicians as a ‘Chronic, relapsing dependence syndrome, reinforced by sensory, behavioural and social conditioning, entrenched by a powerful withdrawal syndrome’. Combined, these factors make it hard for people to give up and they need expert help to succeed.

Targeting all heavy smokers in primary care, along with those who find it hard to stop, would make a big difference because these patients have the highest risk of becoming ill or dying. All smokers referred for elective surgery should also be encouraged to stop smoking before their operation as evidence showed that smoking delays recovery after surgery.4 Focusing time and resources on interventions to assist long-term smokers to quit would benefit their health and reduce costs to the NHS.

Discussing smoking in primary care settings

NICE guidance recommends at every opportunity to ask people if they smoke and offer advice on how they can stop, in a way that is sensitive to their preferences and needs.4 Ideally, all smokers would be offered ‘Very Brief Advice’, comprising of the 3As: Ask, Advise and Act. The National Centre for Smoking Cessation and Training provide online training showing how to apply the 3As in clinical practice. After completing a short assessment staff will qualify for a CPD certificate.

Try opening the dialogue with questions such as ‘What’s getting in your way of stopping smoking?’ or ‘What have you heard about the risks of smoking?’ and ‘May I explain how your body is affected?’. Take an exhaled carbon monoxide test and interpret the result to emphasize the harm of smoking.

Let them know how you can help. Inform all smokers of the support that is available through the NHS and offer a referral to a stop smoking service. Many GP practices and pharmacies have staff trained to provide expert support. The best way to stop smoking is to use a combination of specialist help plus licensed medication, such as short-term and long-term nicotine replacement therapy, and bupropion or varenicline.5

If people are not ready to stop smoking

Help them understand that stopping smoking will reduce their risks of developing smoking-related illnesses or worsening their current condition and personalise this information.4

For example, many people with COPD do not understand the immediate advantages of stopping smoking. Ask about the current problems their lung disease is causing, then ask if they’d like to stop these getting worse? If they don’t want to stop smoking, ask them to consider adopting a harm reduction approach as described in the NICE guideline on smoking: harm reduction,5 and encourage them to seek help to quit smoking in the future.

Harm reduction approaches recommended by NICE5

  • Stopping smoking using licensed nicotine-containing products as long as needed
  • Cutting down prior to stopping smoking, with or without the help of licensed nicotine-containing products
  • Smoking reduction, with or without the help of licensed nicotine-containing products
  • Temporary abstinence from smoking, with or without the help of licensed nicotine-containing products

E-cigarette use

At this stage patients may tell you they have tried vaping or using other electronic devices. Although these products are not licensed medicines, they are regulated by the Tobacco and Related Products Regulations 2016.4 Evidence suggests that e-cigarettes are substantially less harmful to health than smoking but they are not risk-free.6 People who smoke should therefore not be discouraged from switching to e-cigarettes, and be advised to only use those and stop using any tobacco.4

It is time for everyone to renew their efforts to address long-term tobacco use and prevent premature deaths.

Further information and training

  • The National Centre for Smoking Cessation and Training (ncsct.co.uk)

Jennifer Percival is an independent national stop smoking trainer

This project was initiated and funded by Teva Respiratory. Teva have had no influence over content. Topics and content have been selected and written by independent experts.

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