Presentation from the International Congress of the Royal College of Psychiatrists 24-27 June 2014, London

1. NICE Guidance on smoking cessation in mental health settings
Royal College of Psychiatry International Congress.
Professor Mike Kelly, Director of the Centre for Public Health, NICE and the Institute of Public Health, University of
Cambridge.

2. NICE
The National Institute for Health and
Care Excellence (NICE) is the
independent organisation in the UK
responsible for providing national
guidance to the NHS, local
authorities and the wider public
health community on the promotion
of good health and the prevention
and treatment of ill health.

3. The pillars of our work
• Comprehensive evidence
base
• Expert input
• Patient and carer involvement
and community engagement.
• Independent advisory
committees
• Lengthy consultation
• Regular review
• Open and transparent
process.

4. • Smoking cessation in secondary care:
acute, maternity and mental health
services PH48
• http://guidance.nice.org.uk/PH48/Guidanc
e/pdf/English

5. What the guidance was not:
• About banning smoking;
• About disciplining staff;
• About punishing relatives.

6. It is about
• Providing support and help for people
addicted to nicotine deal with their
addiction while in hospital.

7. Background.
• Smoking prevalence is particularly high among people
with mental health problems, and has changed little in
this group in the past 20 years.
• Most of the reduction in life expectancy among people
with serious mental illness is attributable to smoking.

8. • Treating smoking-related illnesses in people with mental
health problems costs the NHS £720 million a year.
• Smoking increases psychotropic drug costs in the UK by
up to £40 million.

9. • 33% of people with mental health problems and 70% of
people in psychiatric units smoke tobacco.
• Smoking is common among young people with mental
health problems.
• Young people aged 11–16 years with an emotional,
hyperkinetic or conduct disorder were much more likely
to be smokers (19%, 15% and 30% respectively) than
other young people (6%)

10. • People with mental health problems are just as likely to
want to stop as the general population – and are able to
stop when offered evidence-based support.
• Effective stop smoking treatment is not always offered.

11. • There is a lack of support for smoke free policies among healthcare
staff working in mental health.
• Staff report lacking specific knowledge about the influence of
smoking – and cessation activities – on a person’s mental health.
• Some physicians unaware that the dosage of some antipsychotic
medications may need to be reduced when a person stops smoking
.

12. Principles.
• Secondary care providers have a duty of care to protect
the health of, and promote healthy behaviour among,
people who use, or work in, their services.
• This duty of care includes providing them with effective
support to stop smoking or to abstain from smoking while
using or working in secondary care services.

13. • The guidance aimed to support smoking cessation,
temporary abstinence from smoking and smoke free
policies in all secondary care settings.

14. Main recommendations.

15. • There must be strong leadership and management to
ensure secondary care premises (including grounds,
vehicles and other settings involved in delivery of
secondary care services) remain smoke free and to help
to promote non-smoking as the norm for people using
these services.

16. • All hospitals should have an on-site stop smoking
service.
• People who smoke should be offered support at the first
opportunity, be advised to stop, provided with
pharmacotherapy and intensive behavioural support.

17. • Providing intensive behavioural support and
pharmacotherapy should be an integral component of
secondary care.
• Continuity of care should be the goal on into the
community.

18. • Staff should be trained to support people to stop
smoking while using secondary care services.
• Staff should be supported to themselves stop smoking or
to abstain while at work.
• There should be no designated smoking areas, no
exceptions for particular groups, and no staff-supervised
or staff-facilitated smoking breaks for people using
secondary care services.

19. Who is this guidance for?
• The guidance is for: commissioners, clinical leads in
secondary care services, health and social care
practitioners, leaders of the local health and care
system, managers of clinical services, estate managers
and other managers, trust boards, and other staff with
any aspect of secondary care or public health as part of
their remit.

20. Recommendation 3 Provide
intensive support for people
using acute and mental health
services

21. • Discuss current and past smoking behaviour and
develop a personal stop smoking plan as part of a review
of patients’ health and wellbeing.
• Provide information about the different types of stop
smoking pharmacotherapies and how to use them.
• Provide information about the types of intensive
behavioural support available.

22. • Offer and arrange or supply prescriptions of stop
smoking pharmacotherapies.
• For anyone who does not want, is not ready or is unable
to stop completely, encourage the use of licensed
nicotine-containing products to help them abstain and
provide intensive behavioural support to maintain
abstinence from smoking while in secondary care.

23. • Offer, and if they agree, use measurements of exhaled
carbon monoxide during each contact, to motivate and
provide feedback on progress.
• Alert the person’s healthcare providers and prescribers
to changes in smoking behaviour because other drug
doses may need adjusting

24. • In addition, for people admitted to a secondary care
setting:
– Provide immediate support if necessary, and
otherwise within 24 hours of admission.
– Provide support (delivered in the setting) as often and
for as long as needed during admission.
– Offer weekly sessions, preferably face-to-face, for a
minimum of 4 weeks after discharge. If it is not
possible to provide this support after discharge,
arrange a referral to a local stop smoking service.

25. • In addition, for people receiving secondary care services
in the community or at outpatient clinics :
– Provide immediate support in the outpatient setting.
– Offer weekly sessions, preferably face-to-face, for a
minimum of 4 weeks after the date they stopped
smoking. Arrange a referral to a local stop smoking
service, if preferred by the person.

26. • Ensure people who use drugs that are affected by
smoking (or stopping smoking) are monitored, and the
dosage adjusted if appropriate. Drugs that are affected
include clozapine, olanzapine, theophylline and warfarin.

27. Conclusions
• Key health inequalities and social justice
issue.
• Evidence of successes.
• Opposition from professionals and
managers.
• A worthy aspiration.