Referrals to stop smoking section services

In the UK, the NHS stop smoking services were set up with the simple aim of helping people to stop smoking. These services implement different cessation methods which can be based around behaviour change techniques.

Whilst these can be used in combination with nicotine replacement therapy, it is counselling services that are unique to the stop smoking services. Dependent on multiple factors, such as funding and service setup, behaviour change sessions can be via group therapy or individual support. It is shown that both methods in isolation have a positive outcome on cessation techniques.

We must note that not all individuals wish to utilise stop smoking services, meaning brief intervention from potential referral sources should always be undertaken in the first instance. When we consider it can take smokers up to 30 attempts to successfully quit, it is important for practitioners to reinforce simple cessation advice and offer stop smoking service referral at every opportunity.

In 1998, the UK government outlined new policies to combat tobacco addiction in the White Paper ‘Smoking Kills.’ By 2001, this guidance had resulted in the nationwide introduction of the precursor to the current stop smoking service; the ‘Smoking Cessation Services.’. These services were ultimately shown to be successful.

Gradually, this service has evolved into the ‘NHS Stop Smoking Service,’ we currently utilise to assist individuals in their cessation attempts. For example, it was found initially that cessation attempts in poorer areas were less likely to be successful than those in less socioeconomically deprived areas.

Increased advertising, alongside encouraging healthcare practitioners to refer these individuals to stop smoking services, means during the past 15 years there has been an increased amount of successful engagement with smokers from disadvantaged communities.

Referral Sources

General Practice

General medical practitioners hold an important role in smoking cessation, with 70% of smokers visiting their GP at least once a year. There is also evidence to show that motivated physicians facilitate successful smoking cessation. If all physicians offered routine, standardised cessation advice the cumulative increase in quit rates could be substantial.

GPs may choose not to discuss smoking cessation as they believe it can damage the doctor patient relationship, however there is evidence that well managed cessation techniques can actually improve the doctor patient relationship.

GPs also have the ability to prescribe smoking cessation aids, which can enhance successful quit attempts two-fold.

We must view every GP appointment with a smoker where cessation is not discussed as a missed opportunity.


99% of the UK population live within 20minutes of a pharmacy, either by foot or by public transport. An estimated 1.6 million individuals visit a pharmacy every day. The pharmacist is therefore in a privileged position as they have regular interactions with large numbers of individuals when they are both ‘healthy’ and ‘sick’.

Whilst pharmacists are trained in nicotine replacement therapy use and behavioural support to assist in smoking cessation, there are issues identified by pharmacists in delivery of this information.

For example, pharmacists believe they don’t always have enough time due to dispensing duties to give adequate advice. It is shown, however, that cessation advice given by pharmacists is beneficial in increasing successful cessation.


59% of the UK population regularly visit a dentist. Dentists are perfectly positioned to notice the impact of tobacco use in the mouth, in both smoked and smokeless forms. Potential oral sequelae experienced by smokers include red and white patches, nicotinic stomatitis and periodontitis.

More threatening to patients than these is that tobacco exposes the oral cavity to carcinogens which initiate and promote oral cancers; these account for 2% of all cancer diagnoses in the UK.

Dental teams are in the enviable position of being able to offer advice to a largely ‘healthy’ section of the population who engage in tobacco use. Brief 2-minute advice from dental practitioners can lead to a 2% increase in successful smoking cessation.


Smoking is the single greatest controllable risk factor in the development and proliferation of age relatedmacular degeneration. It is also implicated in the development of nuclear cataract.

It is documented that the use of optometrists as a healthcare professional to provide brief smoking cessation is underutilised. Despite this, it appears there is an appetite by optometrists to be involved in provision of cessation advice.

We can conclude optometrists provide a further opportunity to deliver brief advice to those who utilise tobacco and offer referral to stop smoking services when appropriate.

Maternity Services

Smoking has numerous effects on a mother and her baby. It reduces the amount of available oxygen to mother and baby, it increases the heart rate of the child alongside increasing the incidence of premature birth, low birth weight, miscarriage and stillbirth.

Smoking can also cause sudden infant death syndrome and increases the risk of the baby developing respiratory problems. 12% of pregnant women smoke throughout their pregnancy term, with these infants more likely to become smokers themselves.

As maternity services have the largest access to pregnant smokers, they can give brief cessation to these individuals alongside referral to NHS stop smoking services.

Interestingly, NRT is found to be of limited use amongst pregnant women beyond their first trimester.

Behaviour management strategies are shown to be effective for pregnant women, but not their partners. This is problematic, as second hand smoke can have similar deleterious health outcomes for the mother and her child.

Secondary Care

Smokers have a significantly increased risk of cardiopulmonary and wound related post-operative complications than their non-smoking counterparts. A preoperative period of cessation of 6-8 weeks shows to greatly reduce the risks of post-operative complications.

In head and neck cancer patients, a period of just three weeks has shown to be beneficial. Therefore, a pre-operative assessment within a secondary care environment gives a perfect opportunity to recommend cessation and advise of potential post-operative risks to smokers.

Hospital admission can be useful in promoting smoking cessation; it imposes temporary smoking abstinence and the environment assists in making individuals aware of the health implications of smoking.

If initial cessation ideology is imparted during the inpatient stay, followed by one month of continued support (for example from stop smoking services) individuals are more likely to successfully stop smoking.

References and Bibliography
Abroms LC, Westmaas JL, Bontemps-Jones J, Ramani R, Mellerson J. A content analysis of popular smartphone apps for smoking cessation. American journal of preventive medicine. 2013 Dec 31;45(6):732-6.
Anderson C, Blenkinsopp A, Armstrong M. Pharmacists’ perceptions regarding their contribution to improving the public’s health: A systematic review of the United Kingdom and international literature 1990-2001. International Journal of Pharmacy Practice 2003;11:111–20.
Bauld L, Chesterman J, Judge K, Pound E, Coleman T. Impact of UK National Health Service smoking cessation services: variations in outcomes in England. Tobacco control. 2003 Sep 1;12(3):296-301.
Bluman LG, Mosca L, Newman N, Simon DG. Preoperative smoking habits and postoperative pulmonary complications. Chest Journal. 1998 Apr 1;113(4):883-9.
Bluman LG, Mosca L, Newman N, Simon DG. Preoperative smoking habits and postoperative pulmonary complications. Chest Journal. 1998 Apr 1;113(4):883-9.
Borland, R.; Partos, T.R.; Yong, H.H.; Cummings, K.M.; Hyland, A. How much unsuccessful quitting activity is going on among adult smokers? Data from the International Tobacco Control 4-Country cohort survey. Addiction 2012, 107, 673–682.
British Dental Association. Opportunistic oral cancer screening. BDA occasional paper, April. 2000 Apr.
Chaiton M, Diemert L, Cohen JE, Bondy SJ, Selby P, Philipneri A, Schwartz R. Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open. 2016 Jun 1;6(6):e011045.
Chan BC, Koren G. Pharmacological treatment for pregnant women who smoke cigarettes. Tobacco induced diseases. 2003 Sep 15;1(3):1.
Chapman S. The role of doctors in promoting smoking cessation. BMJ 1993;307:518–9.
Chesterman J, Judge K, Bauld L, Ferguson J. How effective are the English smoking treatment services in reaching disadvantaged smokers?. Addiction. 2005 Apr 1;100(s2):36-45.
Chestnutt I. Dental public health at a glance. Cardiff: Wiley-Blackwell; 2016. P.17
Chestnutt, I., What should we do about patients who smoke? Dental Update, 1999. 26: p. 227-231.
Cnattingius S. The epidemiology of smoking during pregnancy: smoking prevalence, maternal characteristics, and pregnancy outcomes. Nicotine & Tobacco Research. 2004 Apr 1;6(Suppl 2):S125-40.
Coleman T, Murphy E, Cheater F. Factors influencing discussion of smoking between general practitioners and patients who smoke: a qualitative study. British Journal of General Practice 2000;50(452):207–10.
Department of Health. Pharmacy in England: Building on strengths – delivering the future – proposals for legislative change. London: Department of Health; 2008. Available at:
Department of Health. Smoking kills: a white paper on tobacco. London: Department of Health, 1997. URL:
Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one‐year outcomes. Addiction. 2005 Apr 1;100(s2):59-69.
Fulton EA, Brown KE, Kwah KL, Wild S. StopApp: Using the Behaviour Change Wheel to Develop an App to Increase Uptake and Attendance at NHS Stop Smoking Services. InHealthcare 2016 Jun 8 (Vol. 4, No. 2, p. 31). Multidisciplinary Digital Publishing Institute.
Furber, A. Electronic cigarettes: Reasons to be cautious. Thorax 2015, 70, 307–308.
Hajek, P.; Etter, J.; Benowitz, N.; Eissenberg, T.; McRobbie, H. Electronic cigarettes: Review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction 2014, 109, 1801–1810.
Health Education Authority. Health promotion and the community pharmacist. London: HEA, 1994.
Jamal A, Dube SR, Malarcher AM, Shaw L, Engstrom MC, Centers for Disease Control and Prevention (CDC). Tobacco use screening and counseling during physician office visits among adults—National ambulatory medical care survey and national health interview survey, United States, 2005–2009. MMWR Morb Mortal Wkly Rep. 2012 Jun 15;61(Suppl):38-45.
Jarvis MJ, Foulds J. Effectiveness of smoking cessation initiatives. BMJ. 2002 Mar 9;324(7337):608-.
Kapur B, Hackman R, Selby P, Klein J, Koren G. Randomized, double-blind, placebo-controlled trial of nicotine replacement therapy in pregnancy. Current Therapeutic Research. 2001 Apr 30;62(4):274-8.
Kelly, S. P., Thornton, J., Edwards, R., Sahu, A. and Harrison, R. A. (2005) The causal association between tobacco smoking and cataract. J. Cataract. Refract. Surg. 31, 2395–2404.
Kmietowicz, Z. Action is needed to boost uptake of stop smoking services, say campaigners. BMJ 2015.
Kottke TE, Brekke ML, Solberg LI, Hughes JR. A randomized trial to increase smoking intervention by physicians. Doctors Helping Smokers, Round I. JAMA 1989;261:2101–6.
Kotz D, Brown J, West R. Predictive validity of the Motivation To Stop Scale (MTSS): a single-item measure of motivation to stop smoking. Drug and Alcohol Dependence. 2013 Feb 1;128(1):15-9.
Kuri M, Nakagawa M, Tanaka H, Hasuo S, Kishi Y. Determination of the duration of preoperative smoking cessation to improve wound healing after head and neck surgery. The Journal of the American Society of Anesthesiologists. 2005 May 1;102(5):892-6.
Leonardi-Bee J, Britton J, Venn A. Secondhand smoke and adverse fetal outcomes in nonsmoking pregnant women: a meta-analysis. Pediatrics. 2011 Apr 1;127(4):734-41.
Lichtenstein E, Hollis J. Patient referral to a smoking cessation program: who follows through?. Journal of Family Practice. 1992 Jun 1;34(6):739-45.
Maguire TA, McElnay JC, Drummond A. A randomized controlled trial of a smoking cessation intervention based in community pharmacies. Addiction 2001;96(2):325–31.
McNeill A, Raw M, Whybrow J, Bailey P. A national strategy for smoking cessation treatment in England. Addiction. 2005 Apr 1;100(s2):1-1.
Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. The Lancet. 2002 Jan 12;359(9301):114-7.
Monaghan N. What is the role of dentists in smoking cessation. Br Dent J. 2002 Dec 7;193(11):611-2.
Murray RL, Leonardi-Bee J, Marsh J, Jayes L, Li J, Parrott S, Britton J. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ: British Medical Journal. 2013;347.
Nagelhout GE, de Korte-de Boer D, Kunst AE, van der Meer RM, de Vries H, van Gelder BM, Willemsen MC. Trends in socioeconomic inequalities in smoking prevalence, consumption, initiation, and cessation between 2001 and 2008 in the Netherlands. Findings from a national population survey. BMC Public Health. 2012 May 18;12(1):1.
Nuttall NM, Bradnock G, White D, Morris J, Nunn J. Adult dental health survey: Dental attendance in 1998 and implications for the future. British Dental Journal. 2001 Feb 24;190(4):177-82.
Polosa R, Rodu B, Caponnetto P, Maglia M, Raciti C. A fresh look at tobacco harm reduction: the case for the electronic cigarette. Harm reduction journal. 2013 Oct 4;10(1):1.
Raw M, McNeill A, West R. Smoking cessation guidelines for health professionals. A guide to effective smoking cessation interventions for the health care system. Thorax 1998; Suppl. 5: 1–38.
Rigotti NA, Clair C, Munafo MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev2012;5:CD001837.
Royal Pharmaceutical Society of Great Britain. Pharmacists’ ethical and professional performance: a consultation document on a new code of ethics. The Pharmaceutical Journal 1999;263:CE1–10.
Solberg LI, Boyle RG, Davidson G, Magnan SJ, Carlson CL. Patient satisfaction and discussion of smoking cessation during clinical visits. Mayo Clinic Proceedings 2001;76(2): 138–43.
Solberg LI, Boyle RG, Davidson G, Magnan SJ, Carlson CL. Patient satisfaction and discussion of smoking cessation during clinical visits. Mayo Clinic Proceedings 2001;76(2): 138–43.
Stapleton J. Cost effectiveness of NHS smoking cessation services. London, Kings College. 2001 Sep:1-4.
Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. The Cochrane Library. 2008 Apr 16.
Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. The Cochrane Library. 2008 Jan 23.
Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 1.[Art. No.: CD000146
Tager IB, Hanrahan JP, Tosteson TD, Castile RG, Brown RW, Weiss ST, Speizer FE. Lung function, pre-and post-natal smoke exposure, and wheezing in the first year of life. American Review of Respiratory Disease. 1993 Apr;147(4):811-7.
Thompson C, Harrison RA, Wilkinson SC, Scott‐Samuel A, Hemmerdinger C, Kelly SP. Attitudes of community optometrists to smoking cessation: an untapped opportunity overlooked?. Ophthalmic and Physiological Optics. 2007 Jul 1;27(4):389-93.
Thornton J, Edwards R, Mitchell P, Harrison RA, Buchan I, Kelly SP. Smoking and age-related macular degeneration: a review of association. Eye. 2005 Sep 1;19(9):935-44.
Tobacco Advisory Group of the royal College of physicians, nicotine addiction in Britain, London, royal College of physicians of London, 2000.
Todd A, Copeland A, Husband A, Kasim A, Bambra C. The positive pharmacy care law: an area-level analysis of the relationship between community pharmacy distribution, urbanity and social deprivation in England. BMJ open. 2014 Aug 1;4(8):e005764.
West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update.. Thorax 2000;55:987–99.
West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax. 2000 Dec 1;55(12):987-99.
West R, Walia A, Hyder N, Shahab L, Michie S. Behavior change techniques used by the English Stop Smoking Services and their associations with short-term quit outcomes. Nicotine & Tobacco Research. 2010 May 17:ntq074.
Wiltshire S, Bancroft A, Parry O, Amos A. ‘I came back here and started smoking again’: perceptions and experiences of quitting among disadvantaged smokers. Health Education Research. 2003 Jun 1;18(3):292-303.
Quit Smoking by Henrik Jensen. Available at Licenced under CC BY-SA 2.0
teeth black. breath black. lungs black. stop smoking by Ava Randa. Available at licenced under CC BY-ND 2.0
AMD by National eye Institute. Available at licenced under CC BY 2.0
Man with Periodontitis in Dhaka Housing Slum by United Nations Photo. Available at licenced under CC BY-NC-ND 2.0