Newcastle Declaration: Briefing Note

Newcastle Declaration: Briefing Note


Briefing note on NHS Smokefree Pledge

What is the NHS Smokefree Pledge?

In signing the NHS Smokefree Pledge,NHS organisations commit to reducing the harm caused by tobacco, through implementing NICE Guidance on supporting smokers in the healthcare system to quit.

The NHS Smokefree Pledge builds on existing commitments set out in the NHS Five Year Forward View and Tobacco Control Plan for England, as well as other national policies.

Amongst others, the Pledge has been endorsed by NHS England, the Public Health Minister and Public Health England.

What does signing the NHS Smokefree Pledge mean?

Signing the NHS Smokefree Pledge is a statement of intent and should be done as a way to publically communicate to staff, patients and the wider community the commitments being made to tackle smoking.

The document is signed by individuals in leadership positions within NHS organisations and this highly visible leadership can be supported through communications work and accompanying strategic activity as a means to reshape organisations to best support smokers.

Signatory organisations should contact: to ensure they are listed on the Pledge website and are provided with supportive materials. Organisations that would like further information should also contact the above address or call 020 7404 0242.

This note provides background information to the commitments in the Pledge and advice to NHS organisations about how they can seek to fulfil them.

In signing the NHS Smokefree Pledge, organisations commit to:

  1. Treat tobacco dependency among patients and staff who smoke as set out in the Tobacco Control Plan for England

Ensuring smokers using or working in the NHS get support to quit is one of the key themes of the Government’s Tobacco Control Plan, which states: “NHS Trusts will encourage smokers using, visiting and working in the NHS to quit with the goal of creating a smokefree NHS by 2020 through the Five Year Forward View mandate.”[1]

The Five Year Forward View and supporting documents commit the NHS to taking action to reduce smoking rates and working with partners in local government to achieve this.[2] This includes implementing NICE Guidance which sets out the support that should be offered to smokers in the healthcare system.

Supporting people to quit smoking is also highlighted as an important step in treating many other conditionsincluding CVD, COPD and lung cancer. Research has found that approximately a third of lung cancer patients were smoking at diagnosis. Those who stopped smoking and survived their treatment lived nearly twice as long as those who did not stop smoking after diagnosis.[3]

The principle of smoking cessation as treatment is reflected in The Five Year Forward View which states that: “The relationship between tobacco and cancer is well known, and we will ensure everyone who smokes has access to high quality smoking cessation services”. This is also reflected in the Cancer Strategy which emphasises the importance of the ‘Making Every Contact Count’ principle to improve public health at every available opportunity and argued, prior to its publication, that the Tobacco Control Plan should: “highlight the importance of NHS action [to reduce smoking rates] in primary and secondary care, in particular among those with long term conditions.”[4] This is reflected in the Tobacco Control Plan and requires action across all levels of the NHS, to achieve the targeted reduction in cancer rates by 2020.

The Five Year Forward View for Maternity[5] also acknowledges the major impact smoking has on outcomes, noting that: “Smoking is the single biggest modifiable risk factor for poor birth outcomes” and highlighting the importance of Trusts implementing the Saving Babies’ Lives Care Bundle[6] in which action to tackle smoking makes up one of four elements.

The Five Year Forward View for Mental Health[7] again notes the major contribution that smoking makes to the reduced life expectancy and prevalence of illness and disability in the mental health population. It specifically notes the importance of primary care interventions to support people to make a quit attempt, the importance of people with mental health condition being able to access stop smoking support and recommends that all mental health units be smokefree by 2018.

  1. Ensure that smokers within the NHS have access to the medication they need to quit in line with NICE guidance on smoking in secondary care

National Institute of Health and Care Excellence (NICE) Guidance PH48: Smoking, acute, maternity and mental health services,[8] sets out the requirement for pharmacotherapies to be available to smokers in the NHS, to support both quitting smoking and abstinence. This guidance should be implemented in tandem to NICE Guidance PH45: Smoking: Harm reduction.[9] The harm reduction guidance sets out how smokers can be supported to use safer forms of nicotine that do not contain or burn tobacco as a means of abstaining from smoking, cutting down or to prevent relapse.

Nicotine replacement therapy (NRT) such as patches or nicotine gum should be readily available to all smokers within the NHS. Alongside this smokers and their healthcare professionals should consider using a stop smoking medication such as varenicline (marketed as Champix) or bupropion. NRT and these medications can support smokers both to quit long term but also to abstain from smoking while using the NHS and receiving care.

In supporting a harm reduction approach, trusts must consider their policyon electronic cigarettes which are being used by around three million people in the UK.[10] The most common reasons cited for using an electronic cigarette is to help smokers quit or as an aid to help someone stay off tobacco.9 Evidence shows that these devices are significantly less harmful than smoking tobacco[11],[12] and that they are being used in successful quit attempts.[13]

It is important for NHS organisations to consider this evidence base when setting policies on the use of electronic cigarettes, which should be done with the aim of providing the best possible support to smokers. PHE have produced a number of policy documents around the use of e-cigarettes that can support local decision making process[14],[15],10.

  1. Create environments that support quitting through implementing smokefree policies as recommended by NICE

Implementation of comprehensive smokefree policies promotes a healthy environment that supports and prompts attempts to quit or abstain from smoking. NICE Guidance PH48: Smoking, acute, maternity and mental health settings[16], sets out how implementing a smokefree policy means more than preventing smoking, but needs to include treating tobacco dependence among patients and staff.

A comprehensive smokefree policy should include:

  • Asking all smokers about their smoking status and making brief interventions to recommend that all smokers think about quitting;
  • Providing access to smoking cessation medications for smokers to either quit or temporarily abstain from smoking while on NHS sites;
  • Offering intensive support to people with mental health conditions and pregnant women;
  • Making referrals to specialist stop smoking services either provided by the NHS or local authorities;
  • Ensuring that local policies support harm reduction options for those smokers not yet willing or able to quit;
  • Implementing a smokefree policy which prohibits staff supervised, or facilitated smoking breaks in secondary care;
  • Having leadership and accountability at the highest levels for the implementation of smokefree policies and support to patients, staff and visitors that smoke.

The ‘Next Steps on the Five Year Forward View 2017’ document sets out a timetable for all NHS trusts to become smokefree: “In 2017/18, all mental health trusts will become smoke-free, expanding to all acute trusts in 2018/19, leading to all NHS estates becoming smoke-free by 2019/20.”[17]

  1. Deliver consistent messages to smokers about harms from smoking and the opportunities to quit in line with NICE guidance on brief advice

NICE Guidance on smoking cessation includes recommendations to deliver brief advice to smokers. Brief advice is comprised of three steps: ask, advice and act.

The first step is asking all patients in the NHS about their smoking status. A British Thoracic Survey audit from 2016 found that more than 1 in 4 hospital patients were not asked if they smoke, and nearly 3 out of 4 smokers were not asked if they would like support to quit.[18] Asking patients whether they smoke should be a routine part of hospital and GP appointments as identifying smokers is key to improving health outcomes.

The second part of brief advice is delivering advice to smokers about the harms of smoking, recommending they consider quitting and letting them know what support is available locally to help them quit. This means that local NHS organisations must have an awareness of local authority provided stop smoking services and how they operate.

The final step is ‘act’ this means delivering support to smokers either through making a referral to a stop smoking service or offering pharmacological support through NRT or smoking cessation medications. In their audit the British Thoracic Society found that of the smokers who were asked if they would like to quit, only 20% were referred to a hospital stop smoking service and only 7% were referred to a community-based service.17 Smokers are four times more likely to quit with the support of a specialist stop smoking service compared to quitting unaided,[19] and the services are also effective at reducing health inequalities. To improve outcomes for smokers the number of referrals must increase.

Following the 2016 audit, the British Thoracic Society has published a set of quality improvement tools for hospitals, setting out how to improve therecording of smoking status and referral to specialist support, prescription of nicotine replacement therapy and the training of frontline staff.[20]

Staff need to receive training in how to deliver very brief advice, what to include and how to respond to common questions. This will ensure that smokers are receiving consistent advice from healthcare professionals which is a key motivator of quit attempts. The National Centre for Smoking Cessation and Training provides a range of resources to support training including a free online training module on delivering Very Brief Advice[21].

  1. Actively work with local authorities and other stakeholders to reduce smoking prevalence and health inequalities;

The Five Year Forward View acknowledges the severe contribution that variation in smoking rates makes to health inequalities; stating that: “More than half of the inequality in life expectancy between social classes is now linked to higher smoking rates amongst poorer people.”2

Smokers are more likely to be treated by the NHS and come into contact with healthcare professionals on a regular basis. The NHS therefore has a key role to play in ensuring smokers reach the best support available locally.

With the variety in types of stop smoking services increasing across the country, local NHS teams must work closely with their local authorities to ensure there are referral pathways in place for those who need specialist support to quit.

This is especially important for groups with very high rates of smoking such as people with mental health conditions where smoking rates have remained stable at approximately 40% for the last 20 years.[22] These smokers need specialist support both in hospital and in the community, meaning the NHS, local authority public health teams and voluntary and community organisations need to work together to ensure there is continuity of care.

There are also geographical inequalities in smoking clearly shown through rates of smoking during pregnancy – measured at time of delivery – which vary from less than 3% among some CCGs in London to over 28% in the North West.[23] There is a clear evidence base, set out in NICE PH26[24] and implemented through evaluated programmes such as BabyClear,[25] to show that carbon monoxide screening at first booking with a system of opt out referrals in place for all women who have elevated readings, is important at reducing rates of smoking during pregnancy.

CCGs must ensure that there are evidence based programmes in place to support different groups of smokers and appropriate referral routes.

To help local areas achieve these aims Public Health England has published a CLeaR Deep Dive tool which can help local areas to undertake an assessment of the progress their making against implementing NICE Guidance in acute settings, mental health and pregnancy services. Further information can be found at

  1. Protect tobacco control work from the commercial and vested interests of the tobacco industry

The UK is a party to the WHO treaty on tobacco; theFramework Convention on Tobacco Control (FCTC). Article 5.3 of the FCTC commits organisations to protect health policies from the commercial and vested interests of the tobacco industry[26].

Organisations should:

  • Have a clear corporate policy in place on engagement with the tobacco industry which all staff are aware of
  • Review current prescribing practice in line with NICE guidance and the best available evidence

Guidance on the implementation of article 5.3 is available here.

  1. Support Government action at national level

Supporting national action on tobacco is a commitment set out in the Five Year Forward View which states:“The NHS will therefore now back hard-hitting national action on obesity, smoking, alcohol and other major health risks.”2

National mass media campaigns are a vital route for motivating quit attempts and supporting more quit attempts to be successful.[27],[28] They are also highly cost effective. There have been decline in national investment in campaigns in recent years from £25 million in 2009-10 to £5.3 million in 2015.[29] Maintaining national mass media campaigns supports local delivery.

There is further action that is also needed to regulate the tobacco supply chain to ensure children cannot purchase tobacco and to further control the illicit market. Currently no licence is needed for the sale of tobacco. NHS organisations can support calls for full licencing of the tobacco supply chain from manufacturers to retailers to help further drive down smoking prevalence[30].

NHS organisations can also support calls for the tobacco industry to pay to address the harm they cause. Tobacco companies collectively make an estimated £1 billion in profit in the UK alone while playing a major burden on the NHS and other public services. In the US companies are forced to pay a fee based on the number of cigarettes they sell which is used to fund tobacco control work. The same policy introduced in the UK could provide sustainable route to fund efforts to end the smoking epidemic.26

  1. Jointhe Smokefree Action Coalition (SFAC)

The Smokefree Action Coalition is an alliance of over 300 organisations including medical royal colleges, the British Medical Association, the Chartered Trading Standards Institute, the Chartered Institute of Environmental Health, the Faculty of Public Health, the Association of Directors of Public Health and ASH. The Coalition has engaged with Government on a wide range of tobacco control issues, including the introduction of standardisedpackaging for tobacco products. CCGs and NHS trusts can be a voice for the health of local people on the national platform.

The Smokefree Action Coalition is working towards achieving less than 5% smoking prevalence for all social groups by 2035.29

More information about the Coalition and how to join email:

In signing the NHS Smokefree Pledge organisations acknowledge that:

Smoking is the single greatest cause of premature death and disease in our communities

In England alonealmost79,000 people die from smoking-related diseases each year.[31]This is more than the next five causes of premature death put together, including obesity, alcohol, and illegal drugs.[32]Smoking accounts for one third of all deaths from respiratory disease, over one quarter of all deaths from cancer and about one fifth of all cardiovascular deaths.30On average, smoking reduces life expectancy by10 years.[33]

Health interventions are also less successful for those who smoke. If hospitalised,people who smoke are more likely to require longer stays and need intensive care after surgery.[34] They also have an increased risk of emergency readmission after discharge.Furthermore they are at increased risk of post-surgical infection and have lower survival rates from surgery.[35]This has an inevitable cost to society and to the NHS.

  • Supporting information and resources on smoking and tobacco controlby English region down to local authority levelcan be found at
  • Information on the burden of illness and disease caused by smoking for each local authority in England can be found at
  • Information on smoking deaths by region and local authority can be found at

1 in 4 patients in acute settings are smokers and the same number of people working for the NHS also smoke