Our training programme is designed to give you the core knowledge and skills required by stop

smoking practitioners.
By working through the pages on this course and completing the assessment you will be able to
confirm and develop your practice.
The course is based upon evidence-based behaviour change techniques that maximise the
effectiveness of practitioners in helping people to stop smoking.
To begin the course, please click the 'next' button below.
Tobacco control and smoking cessation
Understanding the full range of activities that form a comprehensive tobacco control programme,
and how smoking cessation fits within this, will help you to work effectively with other agencies
involved in tobacco control at local and national level.
Local stop smoking services are part of a much wider tobacco control strategy that aims to:
Make smoking less attractive to young people;
Encourage and support as many smokers as possible to try to stop;
Make tobacco less affordable;
Reduce exposure to environmental tobacco smoke;
Prevent the tobacco industry from promoting its products;
Provide effective communications for tobacco control.
In order for you to be able to provide accurate information to others, and better understand the
context within local stop smoking services operate, it is important you understand current
government policy on tobacco control.
Tobacco control strategies
One of Public Health England's priorities is to accelerate efforts to promote tobacco control and
reduce the prevalence of smoking.
The Public Health Outcomes Framework includes three specific tobacco related indicators:
Adult smoking prevalence;
Smoking prevalence amongst 15 year olds;
Smoking status of mothers at time of delivery.
Healthy Lives, Healthy People
The Department of Health's strategy for tobacco control is called Healthy Lives, Healthy People: A
Tobacco Control Plan for England.
The plan has three key ambitions, which are to reduce smoking prevalence amongst:
Adults - to reduce prevalence from 21.2% to 18.5% or less by the end of 2015;

Young people - to bring regular smoking among 15 year olds down from 15% to 12% or less by the
end of 2015;
Women who are pregnant - to reduce smoking prevalence from 14% to 11% or less by the end of
2015.
Six strands of tobacco control
The strategy supports tobacco control in England across the six internationally recognisable
strands:
Stopping the promotion of tobacco;
Making tobacco products less desirable
Effective regulation of tobacco products;
Helping tobacco users to quit;
Reducing exposure to second hand smoke;
Effective communications for tobacco control.
The role of stop smoking services
Almost three quarters of smokers say they would like to quit. Over one third (39%) go on to make a
quit attempt each year but only a small proportion - about 5% - quit successfully.
Smokers who stop smoking with specialist support and medication are up to four times more likely
to successfully stop compared to smokers who stop without any form of support. This means stop
smoking services deliver life saving interventions and play a role in helping achieve the national
tobacco control targets with regard to smoking prevalence.
Marketing and recruitment
Stop smoking services significantly improve quit rates, yet despite this most smokers still do not
know what their local service can offer.
Understanding the opportunities and challenges posed by the need to recruit smokers into
treatment will help you to inform the development of recruitment strategies in your area and
contribute to the set-up and monitoring of local referral systems.
Formal referral systems for key settings (such as primary and secondary care) will ensure that
smokers are routinely recruited from the broader health and social care system.
Informal self referral systems should also be in place to encourage, and make it easy, for smokers
to get help to stop.
It is important that services evaluate the effectiveness and cost-effectiveness of innovative
methods of generating referrals, such as stop smoking shops and outreach campaigns.
National marketing and communications campaigns are effective at getting more people to use the
local stop smoking services.
Strategies for promoting stop smoking services should be based on local intelligence wherever
possible, but will be enhanced by integration with national and regional campaigns.

Smokefree literature, and other promotional resources can be ordered from the Smokefree
Resource Centre smokefree.nhs.uk/resources.These include templates for local use that can be
customised.
Cost effectiveness
The work of stop smoking practitioners has great value to the NHS, the wider economy and to the
general public.
Smoking cessation interventions have been shown to be one of the most cost-effective of all lifesaving treatments provided within healthcare systems - savings have been calculated to be
somewhere in the region of 1,000 per life year gained, compared with more than 15,000 for the
average life-saving treatment.
The current level of tobacco use is estimated to cost the NHS around 2.7 billion every year.
Understanding these costs to society, and the benefits of stop smoking services, should help you
to persuade others of the importance of local stop smoking services within the context of the local
health economy.
Smoking in the population
Understanding who smokes, what effect smoking has, why people smoke, and how best to help
them stop, is central to the role of a stop smoking practitioner as this provides the context for your
professional practice.
Key facts
As of December 2013 smoking prevalence in England was 19.5%;
Prevalence differs according to age, socio-economic group and ethnicity;
There are currently around 8.5 million smokers in England and this number is falling every year by
just under 1%;
Smoking is declining at the same rate across all socio-economic groups; although until very
recently the drop in smoking rates among lower-income groups was much slower.

Demographics and prevalence

It is important to have an understanding of smoking demographics and prevalence because:
It helps when it comes to understanding smokers' chances of quitting, and tailoring the way that
you interact with them;
If you work in an area with a specific population of smokers, it is important to understand what
impact this may have on referral and attendance to stop smoking services.
Smoking and gender
Although teenage girls are more likely to smoke than teenage boys, by the time they become
adults smoking prevalence is slightly higher in men than in women.

A lot of people think women find it harder to stop smoking than men, this is not normally true. Men
and women find it equally difficult to quit smoking. However, women are more likely than men to
access stop smoking services.
Although women report smoking for weight control more than men and are concerned about weight
gain once they quit, it is not a common reason for relapse back to smoking once they make a quit
attempt.
Smoking and age
Studies have consistently shown that, in the UK:
Smoking prevalence peaks in the mid-twenties;
Younger smokers are more likely to try to stop smoking but less likely to succeed;
Older smokers are more likely to have switched to lower tar cigarettes.
Smoking and ethnicity
Smoking prevalence is not uniform across all ethnic groups: smoking prevalence is much higher in
Bangladeshi men, and slightly higher in Pakistani men than 'white British' men.
Smoking prevalence is much lower in women of all minority ethnic groups than 'white British'
women.
Use of smokeless tobacco such as Paan is common among people of South Asian origin.
Use of waterpipes (shisha or hooka) is also common among people of South Asian origin, in
people of Arabic origin and is growing amongst young people irrespective of their ethnicity.
Asian and African-Caribbean smokers use the local stop smoking services about as much as 'white
British' smokers.
Smoking and socio-economic group
Smoking prevalence is higher in more deprived socio-economic groups: 26% for routine and
manual occupations compared with 14% in managerial and professional groups.
Smoking is the biggest single cause of inequalities in death rates between rich and poor in the UK.
It is extremely important to understand that people from more deprived backgrounds do not lack
motivation to stop or make less quit attempts than more affluent smokers, but they may well need
more help to quit.

Quit attempts
About 4 out of every 10 smokers (39%) have tried to quit in the previous 12 months, but only about
5% of these succeed.
Over half of all smokers (52%) say that they are 'cutting down' on their smoking.
There is no difference between 'lighter' (less dependent) and 'heavier' (more dependent) smokers
in their attempts to stop, but less dependent smokers are more likely to succeed.
The main times for trying to quit are January (because of New Year resolutions), March (because
of No Smoking Day) and, since 2012, October (because of Stoptober).

These seasonal fluctuations impact upon the number of smokers attending local stop smoking
services.
Smoking and health
Smoking is the single most important preventable cause of death and illness.
It causes over 100,000 deaths per year in the UK, 5 million worldwide, and results in the premature
death of half of smokers who do not manage to stop.
Smoking is the cause of long-term illness and disability in many smokers, including those that
ultimately die from something else other than their smoking.
The main causes of death attributable to smoking are:
Cancer;
Cardiovascular disease;
Lung disease.
Cancer, heart and lung disease
Cancer
In the UK, smoking causes over 37,000 people to die from cancer each year, 34,000 of these from
lung cancer.
The risk of lung cancer is 15 times greater for a smoker than a non-smoker. The risk accumulates
over time and is directly related to daily cigarette consumption and how long someone has been
smoking.
About one in eight smokers who do not quit will die of lung cancer.
Other cancers
As carcinogens in cigarette smoke are ingested, dispersed and eliminated throughout the body,
smoking is linked to a large number of cancers other than lung cancer, including:
Throat and mouth cancer;
Bladder cancer;
Kidney cancer;
Stomach cancer;
Pancreatic cancer.
Cardiovascular disease (CVD)
Cardiovascular disease (such as heart attacks and strokes) account for over one-quarter of all
smoking-related deaths.
The average smoker has approximately twice the risk of developing heart disease prematurely
compared to someone who has never smoked, and even light smokers have a substantially
increased risk of cardiovascular disease.

Chronic Obstructive Pulmonary Disease (COPD)

The term COPD encompasses chronic bronchitis and emphysema. In both diseases the lungs lose
their capacity to transfer oxygen to the bloodstream.
About 23,000 people die from COPD as a consequence of smoking, accounting for over one fifth of
all smoking-related deaths each year.
COPD is easy to detect at an early stage through spirometry (a test to measure lung function), and
its progress can be slowed dramatically by stopping smoking
Other diseases and conditions
There are numerous other diseases and conditions, many of which are fatal, caused or made
worse by smoking. A stop smoking practitioner needs to be able to inform smokers about these
other health consequences of smoking:
Age-related hearing loss;
Crohns disease and inflammatory bowel disease;
Type 2 diabetes;
Osteoporosis;
Smokers undergoing surgery are at an increased risk of complications from anaesthesia;
Smokers are more vulnerable to post-surgical complications and delayed wound healing.

Environmental tobacco smoke

It is essential that smokers have accurate information on how their smoking can impact on the
health of others.
There is good evidence to show that exposure to environmental tobacco smoke, also known as
'secondhand smoke' or 'passive smoking', increases the risk of:
respiratory disease;
lung cancer;
coronary heart disease.
Exposure to secondhand smoke in pregnancy has been shown to reduce birth weight which can
have serious consequences for the baby's health and childhood development.
Babies and children who live with parents who smoke have a greater risk of respiratory illness, ear
disease and cot death (Sudden Unexplained Death in Infancy); plus they are more likely to grow up
to be smokers themselves.

'Protective effects' of smoking

Smokers may have heard media reports about the 'positive effects' of smoking, and it is important
to be able to confidently address any false beliefs.
There is actually some evidence to suggest that cigarette smoking may reduce the risk of certain
conditions:
Pre-eclampsia (high blood pressure during pregnancy);
Morning sickness during pregnancy;
Ulcerative colitis;
Parkinsons disease.
Smoking does not completely protect against these conditions.
It is also important to inform smokers that the health benefits of stopping smoking far outweigh the
loss of any 'protective effects' which may occur.
Although many people have heard that smoking is protective against Alzheimers disease, this is
not true.
Health benefits of stopping smoking
It can be motivating for smokers to have information on the benefits of stopping, and it is important
to communicate to smokers that quitting is the best thing they can do for their current and future
health.
It is important for young smokers to realise that they have most to gain by stopping now. Stopping
smoking increases life expectancy at every age but the earlier the smoker stops the better; quitting
at age 35 adds an average of 10 years, while quitting at 65 adds 3 years of life.
Stopping smoking at any age will lead to improvements in physical and mental health.
Key facts that you can tell smokers include:
The risk of lung cancer stops increasing when smokers quit;
The increased risk of heart disease diminishes by 50% within the first year of stopping;
The rate of progression for COPD is drastically slowed once a smoker stops smoking;
Ex-smokers report being healthier, happier and having greater life satisfaction than smokers;
The average smoker saves over 1,500 per year if they quit.

Special populations
Not all smokers are the same.
Some smokers are harder to attract into services than others, some need more support, and for
some their use of stop smoking medications will need special consideration.
The special populations covered in this training course are smokers who:

Are pregnant;
Have mental health problems;
Are drug and alcohol dependent.

Pregnancy and smoking

Smoking and conception
Smoking makes it harder to conceive, irrespective of which partner smokes.
In men, smoking is linked to reduced sperm count, less mobile sperm and higher incidence of
impotence. In women, smoking is linked with hormonal changes that reduce the likelihood of
pregnancy.
Smoking can reduce the likelihood of success of assisted reproductive techniques (e.g., in vitro
fertilization, IVF).
Pregnant and smokers
It is essential to be aware of the special circumstances that arise with pregnant smokers when
determining how best to recruit them to the local stop smoking services, and how to best support
them to successfully stop smoking.
One in eight (12%) mothers reported that they continued to smoke throughout their pregnancy
(down from 17% in 2005). About 25% of women who smoke succeed in quitting when they learn
they are pregnant, but many more would like to stop.
Teenage smokers and smokers from deprived backgrounds are far less likely to succeed in
stopping despite being motivated to stop smoking.
The percentage of women who stop in their first pregnancy is greater than the percentage who
stop in later pregnancies.
Women can be reluctant to admit to being a smoker when asked by health professionals, for a
range of reasons including fear of social stigma.
Effects of smoking in pregnancy
All pregnant smokers should be made aware that smoking increases the risk of both miscarriage
and stillbirth.
Babies born to mothers who smoke are more likely to be born prematurely and with low birth
weight, which itself causes a number of problems.
Babies born to mothers who smoke are twice as likely to die from cot death (Sudden Unexplained
Death in Infancy) as babies born to non-smokers.
The long-term health effects of smoking during pregnancy
Children born to mothers who smoke are more likely to have:
Behavioural problems;

Learning difficulties;
Respiratory problems.
Once you pass this course you will be able to access the NCSCT specialty Pregnancy and the
Post-Partum Period online training module.
Smoking and mental health problems
Smoking prevalence is higher amongst people with mental health problems than it is in the general
population, and is particularly high amongst those with severe mental illness.
There has been reluctance from health professionals to address smoking in this group. Studies
show desire to stop smoking is just as high amongst people with mental health problems as in the
general population, and that stopping smoking does not worsen mental health. However, these
smokers may need higher levels of support to successfully stop.
Smoking and mood disorders
Smoking prevalence is higher in people with anxiety and depression.
Anxiety levels typically go down when people stop but depression usually remains at the same
level.
The vast majority of smokers' report being 'happier' after they have stopped but a few report being
less happy and these may need additional and more intensive support
So that you can reassure smokers that stopping smoking wont worsen their condition, but will in
fact improve it
You need to be vigilant in monitoring the minority of people who become more miserable when
they stop smoking and see what long-term help they might need
Smoking and psychotic illness
The majority of people with schizophrenia and other psychotic disorders smoke, and in most cases
they are very heavy smokers with greatly increased risk of dying from a smoking-related disorder.
There is no evidence to show that smoking helps with psychotic symptoms.
Smoking (mostly through the hydrocarbon agents in cigarette smoke, not nicotine) stimulates a
liver enzyme responsible for metabolising drugs in the body which results in the faster clearance of
a number of medications including:
antipsychotics;
antidepressants;
anxiolytics.
This means that smokers may need higher doses of these drugs than non-smokers.
Stopping smoking can therefore lead to the doses of some medications needing to be reduced to
achieve the same drug level and therapeutic effect.
It is essential to realise that there is no medical reason for people with psychotic illness to continue
to smoke, and that in terms of encouragement to stop they should be treated like any other
smoker. However, there must be the additional understanding that the difficulties they face in
stopping are greater.

Once you pass this course you will be able to access the NCSCT Mental Health Specialty Module.

People with drug and alcohol dependence

Smoking rates are very high in people who have problematic use of drugs and/or alcohol.
Smokers who are also dependent on drugs or alcohol can find it particularly hard to stop smoking.
There is evidence that stopping smoking does not make these other addictions worse, or lead
those who have become drug or alcohol free to relapse.
You need to be able to reassure people with drug and alcohol addictions that stopping smoking will
not make their other addictions worse, but they may need additional and intensive support.
Nicotine
It is important to understand how nicotine acts in the brain to keep people smoking. People's
susceptibility to nicotine, and their social and physical environments also play a crucial role in
keeping them smoking.
It is explained here in some detail because it is useful to be able to help smokers understand why
they are addicted, and why it is difficult to quit smoking.
How nicotine works
Nicotine in cigarette smoke is a drug that mimics a naturally occurring chemical messenger or
'neurotransmitter' called acetylcholine which is present in many parts of the nervous system.
Nicotine attaches itself to receptors on nerves in a part of the brain that is important in controlling
our motivation, called the ventral tegmental area. This causes the nerve cells to become more
active, causing them to release dopamine at the other end of the nerve in an area of the brain
called the nucleus accumbens. This process is important in the development and maintenance of
addiction.
Nicotine absorption and its elimination from the body
Nicotine from cigarette smoke is rapidly absorbed through the large surface area of the lungs, this
results in a nicotine 'hit' reaching the brain within a few seconds of each puff.
Following each cigarette nicotine concentrations in the body fall rapidly, as it is metabolised and
excreted. The concentration falls by half every 90-120 minutes which means that after a nights
sleep most smokers have very little or no nicotine in the body.
Awareness of how quickly nicotine concentrations fall in the body allows you to understand the
onset of withdrawal symptoms and why many smokers need to keep topping up their nicotine
levels by smoking regularly throughout the day.
It also explains the significance of knowing how long after waking they have their first cigarette in
the morning is as a measure of nicotine dependence.

Further information:
Nicotine

Nicotine in cigarettes
On average, smokers get just over 1mg of nicotine from each cigarette but the dose varies
considerably between smokers. If a cigarette is smoked as hard as possible, a smoker can get up
to 6mg nicotine into their system.
It is important that you can explain this to smokers to highlight the inaccuracies of cigarette
labelling of products such as 'lighter' brands, and when discussing how NRT works.

Nicotine addiction
Dopamine is released into the brain by the action of nicotine on neuroreceptors, and acts as a
'chemical reward' or 'teaching signal'. The brain naturally seeks out more of this 'chemical reward'
and does so by motivating us to repeat the behaviour that led to the reward - in this case puffing on
a cigarette.
The dopamine mechanism also creates associations between nicotine reward and cues such as:
Being with smokers;
Times when they would have previously smoked, such as sitting down after a meal;
Being under the influence of alcohol.
This link is completely unconscious and undermines the smokers ability to make rational choices
about the behaviour.
The rapid excretion of nicotine from the body causes withdrawal symptoms which are quickly
relieved by smoking, and this too reinforces their dependence.

Nicotine craving and withdrawals

Smoking causes lasting changes to the brain.
This means that smokers are used to regular doses of nicotine and when there is no, or less,
nicotine in the brain, dopamine levels in the nucleus acumbens are abnormally low. This creates
what is known as an 'abnormal drive state' (much like hunger for food), but in this case the target is
nicotine.
It is experienced as a kind of gnawing hunger for a cigarette or craving.
This is in addition to the cravings triggered by smoking cues.
Habit
Smokers have to 'learn' how to smoke because for many, at first it is usually an unpleasant
experience with feelings of nausea and giddyness.
However, repeating smoking becomes a habit. Nicotine taps into a part of the brain that learns
automatic associations between triggers and actions the part that learns habits. This means that
smokers get automatic impulses to smoke in situations in which they would normally light up,
called 'cues'.

Being in a situation with other smokers, or experiencing events that have previously been
associated with smoking, is a high risk time for smokers trying to stop.
When smokers encounter a cue, they have the impulse to reach for a cigarette. If they consciously
resist this, they experience the impulse as an 'urge' to smoke.
Nicotine withdrawal symptoms
Most smokers will experience unpleasant effects on their mood and physical wellbeing after they
quit and this will contribute to their strong desire to smoke
These include:
Depressed mood;
Irritability;
Restlessness;
Difficulty concentrating;
Increased appetite;
Cough;
Constipation;
Weight gain;
Mouth ulcers.
Most of these can be helped by using one of the stop smoking medications, although they are
unlikely to be eliminated completely.
These withdrawal symptoms mostly last a few weeks, but increased appetite lasts longer, and
some weight gain is usually permanent.
Behavioural support
Research clearly shows that face-to-face behavioural support given over multiple sessions doubles
the chances of a successful quit attempt.
When this support is combined with a smoking cessation medication (NRT, bupropion or
varenicline), the chances of a successful quit attempt are doubled again.
This means that a smoker who attends a stop smoking service, and uses medication as advised,
has a four times greater chance of stopping smoking than someone going cold turkey in an
unsupported attempt.
It is this combination of behavioural support, and effective medication that gives the smoker the
best chance of success at stopping.
Pro-active telephone support where the stop smoking specialist calls the smoker according to a
pre-planned schedule, can also be helpful and can enhance the effect of face-to-face support.

One-to-one behavioural support

Behavioural support works by increasing smokers' motivation not to smoke and reducing
motivation to smoke; at the same time building on their capacity and skills to exercise self-control
and optimising their medication use.
There are a number of evidence-based specific behaviour change techniques (BCTs) involved in
the delivery of effective behavioural support.
BCTs, the things that you say and do with smokers, are effective interventions to improve smokers'
chances of quitting.
The behaviour change techniques that have been shown to be the most important are:
Establishing a good rapport;
Making sure they have a realistic expectation of stop smoking medications, use these medications
properly and that they are aware of any potential side effects;
Making sure the smoker knows what to expect in terms of cravings and withdrawal symptoms;
Helping them to change their routine to avoid smoking;
Using CO monitoring as a motivational tool;
Stressing the importance of the not a puff rule and gaining commitment from them;
Supporting them through their quit attempt and giving praise for not smoking;

Group based behavioural support

Smokers may be anxious about joining a group but group-based support can be particularly
effective.
Wanting approval from our peers is a very important motive for a lot of people, and smokers
attending stop smoking groups report that thinking about what they would say to the group if they
smoked was the thing that stopped them from having a cigarette.
In order to maximise this effect it is important to make sure that smokers are oriented towards the
group and not towards the facilitator.
Closed and rolling groups
Group-based support using a 'closed group' format, where the whole group starts together and has
the same quit date, has the highest success rates of all forms of behavioural support.
'Rolling groups' are where people join the group at different stages in their quit attempt. However
we do not have strong evidence of their effectiveness.
Recruiting patients for group treatment
The effectiveness of group based support can be compromised if the group is too small, and
suffers from too high a rate of relapse and drop out.

For groups to be effective they need to start with a fairly large number of people, ideally 15+ and
certainly more than 10.
This requires a large enough catchment area and a strong recruitment drive. It also requires you to
be experienced in group support and to know the advantages so that you can overcome people's
natural resistance to the idea of a group.
It is also important to screen out people who are not suitable because they would adversely affect
the group process.
Medications overview
As a stop smoking practitioner you need to help smokers make an informed choice about the
medications available to them and to be able to answer any questions or concerns they might
have.
The information given in this training course may differ from that contained in the Medicines and
Healthcare Regulatory Authority (MHRA) approved patient information leaflets that accompany the
medications. This is because the information here is based upon the latest evidence, Cochrane
reviews, NICE guidance and good clinical practice.
This course focuses on those smoking cessation medications approved by the National Institute for
Health and Care Excellence (NICE) to help people stop smoking. However, in the Other
Treatments section we also look at medications that are used less often by smokers and those for
which the evidence of effectiveness is either unclear or non-existent.
An overview of each medication is provided with links to the Summary of Product Characteristics
(SPC) and a Cochrane review via the 'further information' button, where available.
Nicotine Replacement Therapy (NRT) and varenicline (Champix) are the two licenced medications
that are primarily used in the UK to assist smoking cessation, and they are described in some
detail on the following pages.

Nicotine replacement therapy (NRT)

NRT is the term used to describe the range of products that deliver pharmaceutical, clean nicotine
to relieve the withdrawal symptoms smokers experience when they quit.
NRT has been shown to roughly double long-term abstinence rates, compared to going 'cold
turkey'.
NRT only delivers nicotine to the smoker, not the other harmful constituents of tobacco smoke (e.g.
tar and carbon monoxide), and typically delivers less nicotine than cigarettes. It's use is therefore
much safer than continued smoking.
The biggest problem with NRT is that most smokers do not use enough of it for long enough.
Combining a faster acting NRT product with the nicotine patch has been found to increase longterm abstinence rates, and works better than using just one form of NRT.
Ensuring that clients remain on the highest appropriate NRT dose for as long as possible, and for
at least the first 4-6 weeks, will help to reduce their withdrawal symptoms. Clients should use NRT
for at least 8 weeks.

All NRT products are available on prescription. They can also be bought from pharmacies, other
retail outlets such as supermarkets and online.
Combining stop smoking medications
Combination NRT
Evidence shows that using combination NRT is more effective in helping smokers to quit than
using a single NRT product and results in similar quit rates to that of varenicline.
So a combination of nicotine patch (to help with background 'nicotine hunger') and a faster acting
form such as gum, spray, or lozenge (to help deal with 'breakthrough urges to smoke') should be
considered the standard treatment.
Combination NRT offers additional control over withdrawal symptoms because the nicotine patch
provides a steady supply of nicotine throughout the day and the short-acting NRT product (e.g.
gum, lozenge, inhalator, microtab, nasal spray, mouth spray, strips) can be used in response to
cravings or anticipated cravings.
Single forms of NRT should only be offered if smokers, despite having had the benefits fully
explained to them, do not wish to use combination NRT.
Combining NRT with other medications
There is no good evidence that combining NRT with other medications such as bupropion or
varenicline improves success rates.
NRT and pregnancy
It is often recommended that pregnant women should stop smoking without NRT because nicotine
from the NRT will reach the baby.
However, for many this is extremely difficult and NRT will be necessary to help achieve abstinence
and protect the baby from the harms caused by smoking.
Pregnant women metabolise nicotine more quickly which might explain why research conducted so
far (where single-dose NRT was tested) has found little or no effect of NRT. Data from English stop
smoking services however has found that combination NRT significantly improves pregnant
smokers' chances of quitting.
Oral products, such as gum and lozenges, should probably be recommended to pregnant smokers
first because they provide intermittent nicotine to the baby rather than the constant flow provided
by patches - however, feelings of nausea may make oral NRT products difficult to tolerate.
Pregnant smokers using nicotine patches should remove them at night.
The liquorice-flavoured nicotine gum (Nicotinell) is contraindicated in pregnancy.

Once you pass this course you will be able to access the NCSCT specialty Pregnancy and the
Post-Partum Period online training module.

Extended NRT use

Pre-loading with NRT

Using the nicotine patch for two weeks before the quit date has been found to improve the chances
of long-term abstinence, compared with the standard practice of starting NRT use on the quit day.
Pre-loading with NRT allows the smoker to get used to taking the NRT, become accustomed to any
side effects and to experience it working by reducing their need to smoke - all before they have to
deal with not smoking.
Use of NRT in this way could be considered as an option for more dependent smokers and for
those smokers who have had considerable difficulty in quitting in the past or who want to try
something new.
Long-term use
NRT is proven to help people stop smoking and for this it is typically recommended to be used for
8-12 weeks.
However, there is evidence to suggest that some smokers need to continue NRT long-term to
maintain abstinence. Long-term NRT users tend to have been more dependent smokers and the
risk is that they stop using NRT and return to smoking.
There is good evidence that using NRT in the long-term is safe.
Smokers, and their families, often fear that long-term NRT use means that they are still dependent,
and have gained nothing from stopping smoking. They need to be strongly reassured that although
still dependent upon nicotine, they are getting it from a harmless product (NRT) rather than from an
extremely harmful one (cigarettes).
Nicotine Assisted Reduction to Stop (NARS)
Smokers who are not ready to make a quit attempt can use NRT to help them cut down with a view
to stopping later.
Encouraging smokers who are not ready to quit but are open to reducing their consumption by
substituting NRT for the cigarettes they would have smoked, significantly increases the likelihood
that they will eventually go on to give up for good.
Smokers need to be reassured that it is safe to use NRT while smoking; and that health problems
arise from smoking not NRT use, which is safe.
Medication use for harm reduction
In June 2013 NICE published guidance about harm reduction approaches to smoking, which
included recommendations about the use of licensed nicotine containing products, such as NRT, to
reduce the individual harm caused by tobacco.
Such approaches included the long-term use of NRT products by smokers that have quit smoking,
the use of products to support reducing the amount smoked and using NRT for periods of
temporary abstinence (i.e. when people are unable to smoke).

Effect of smoking cessation on other medications

Smoking, mostly through the hydrocarbon agents in cigarette smoke rather than nicotine,
stimulates a liver enzyme responsible for metabolising drugs in the body.
As a result, smoking causes faster clearance of a number of medicines including:
Antipsychotics;

Antidepressants and anxiolytic drugs;

Insulin;
Theophylline.
Smokers may need higher doses of these medications than non-smokers or ex-smokers.
Stopping smoking can lead to the doses of some these medications needing to be reduced by as
much as 50% to achieve the same drug level and therapeutic effect. This is true irrespective of
whether a stop smoking medication is being used or not.
There are currently no guidelines with regard to reducing medication doses when cutting down (but
not stopping) cigarette consumption.
Many healthcare professionals and service users are not aware of the effect of stopping smoking
on drug levels in the blood.
Communication with prescribers from primary and secondary care regarding reduction in doses of
certain medications should occur prior to cessation and continue through the quit attempt.

Nicotine replacement therapies

A detailed knowledge of each Nicotine Replacement Therapy (NRT) product is essential
knowledge for a stop smoking practitioner.
On the following pages each type of NRT is described along with instructions for use, side effects
and contra-indications.
We have also included links to the Summary of Product Characteristics (SPC) for reference.

Transdermal patch
The nicotine transdermal patch is available in 16-hour and 24-hour preparations.
There is no good evidence that the 24-hour patch is better than the 16-hour patch.
Nicotine patches are available in various strengths from 10mg to 25mg; for most smokers the
higher dose patches should be considered 'normal' strength.
Nicotine patches typically deliver about half of the nicotine that smokers get from cigarettes.
Ideally treatment should continue for at least 8 weeks although some smokers will need to use
them for longer.
There is no evidence that step-down approaches that decrease strength over a course of treatment
are any better than using a single dose patch for 12 weeks and then just stopping, but smokers
often like to gradually reduce their use of patches.
Side effects

Nicotine patches have very few side-effects but about 5% (1 in 20) of users find that they have a
skin reaction.
The nicotine patches can result in a burning sensation to the site where they are applied, but this
is usually short lived and can be reduced by changing the site of application each day.
Some smokers using the 24-hour patch often experience wakefulness or vivid dreams at night. If
these are problematic they should be advised to switch to the 16 hour patch, and to have another
form of NRT by the bed to use in the event that they wake in the night experiencing cravings.
Cautions and contraindications
Nicotine patches are contraindicated in:
Those with hypersensitivity to nicotine or any component of the patch; and
Children under 12.

Nicotine patches should be used with caution in smokers with:

Diabetes mellitus
Renal or hepatic impairment
Pheochromocytoma (a rare tumour of the adrenal glands);
Uncontrolled hyperthyroidism;
Dermatological disorders (e.g. psoriasis, chronic dermatitis).
Please refer to the summary of product characteristics (SPC) for a full description.
Oral NRT products
There are currently six NRT products that are administered orally and have common features.
These products are:
Nicotine chewing gum;
Nicotine lozenges;
Nicotine microtabs;
Nicotine mouth spray;
Nicotine inhalator;
Nicotine strips.
All of these products should be used regularly throughout the day to maintain blood-nicotine levels:
'on the hour, every hour' is the instruction given to users.
Nicotine is absorbed through the buccal mucosa (the inside lining of the cheeks). It is not well
absorbed when swallowed in saliva.

It is difficult for smokers to get the amount of nicotine from these products that they got from
cigarettes, and so their effectiveness can be maximised by using them in combination with the
nicotine patch.
Ideally treatment should continue for at least eight weeks, although some smokers will need to use
NRT for longer.
Smokers can use these products for as long as it is helpful. Once they have stopped using the
NRT regularly they could keep a small supply with them to use if a strong urge to smoke occurs.
Below is further information on all these product types.
Nicotine gum
Nicotine chewing gum is available in two strengths: 2mg (about 0.9 mg of nicotine is absorbed) and
4mg (1.2 mg being absorbed).
Nearly all smokers should use the 4mg gum when they quit smoking, with the 2mg gum only being
suitable for some less dependent smokers.
Correct use involves a specific chewing technique. The gum needs to be chewed until there is a
hot peppery taste, and then it needs to be parked against the cheek for the nicotine to be
absorbed.
After a couple of minutes, this process can be repeated. This is known as the chew and park
technique. Chewing too much results in excessive nicotine release and that nicotine being
swallowed in saliva.

Nicotine gum side effects

The common side effects associated with nicotine chewing gum are:
Burning mouth;
Indigestion;
Hiccups;
Jaw ache.
These side-effects become less severe with continued use. Warning smokers of the initial effects
of the gum beforehand, and getting them to practice using it before their quit date, can be helpful.
Gum contains E321 which can cause irritation to the mucous membranes in some patients.
Nicotine gum cautions and contraindications
Nicotine chewing gum is contraindicated in those with hypersensitivity to any component of the
chewing gum.
Nicotine chewing gum should be used with caution in smokers with:
Cardiovascular disease;
Diabetes mellitus
Oesophagitis;

Gastric or peptic ulcers;

Renal or hepatic impairment;
Pheochromocytoma (a rare tumour of the adrenal glands);
Uncontrolled hyperthyroidism.
Nicotine lozenges
There are two types of nicotine lozenge - the standard lozenge which is available in three different
strengths (1mg, 2mg and 4 mg), and the the mini lozenge which is available in two strengths (1.5
mg and 4 mg).
About half the amount of nicotine in the lozenges is absorbed.
The 4mg lozenge is the treatment of choice for most smokers, the 1mg, 1.5 mg and 2mg lozenges
are only suitable for less dependent smokers.
Nicotine lozenge side effects
The common side effects associated with nicotine lozenges are:
Burning mouth;
Indigestion;
Hiccups;
Heartburn (probably due to swallowed nicotine).
These side-effects become less severe with continued use. For many people the nicotine lozenge
tastes quite unpleasant, especially at first, but most patients get used to it and even grow to like it.
Warning smokers of the initial effects of the lozenge beforehand and getting them to practice using
it before their quit date can be helpful.
Nicotine lozenge cautions and contraindications
Nicotine lozenges are contraindicated in those with hypersensitivity to nicotine or any of the
excipients and children under 12.
Nicotine lozenges should be used with caution in smokers with:
Cardiovascular disease;
Diabetes mellitus;
Oesophagitis;
Gastric or peptic ulcers;
Renal or hepatic impairment;
Pheochromocytoma (a rare tumour of the adrenal glands);
Uncontrolled hyperthyroidism;
Phenylketonuria (PKU, an inability to metabolise an essential amino acid);

People on low sodium diet (lozenges contain 15mg sodium)

Nicotine microtabs
The microtab is similar to the nicotine lozenge, only smaller. Patients should place the microtab
under their tongue, where it will slowly dissolve.
It comes in 2mg strength and about half of this nicotine is absorbed.
Nicotine microtab side effects
Users rarely report serious side effects with use of the nicotine microtab. The common side effects
associated with the nicotine microtab are:
Burning mouth;
Indigestion;
Hiccups;
Heartburn (probably due to swallowed nicotine);
These side-effects become less severe with continued use.
For many people the nicotine microtab tastes quite unpleasant, especially at first, however most
smokers get used to the taste and even grow to enjoy it.
Warning smokers of the initial effects of the microtab beforehand and getting them to practice using
it before their quit date can be helpful.
Nicotine microtabs cautions and contraindications
Nicotine microtabs are contraindicated in those with hypersensitivity to any component of the
microtabs.
The nicotine microtabs should be used with caution in smokers with:
Cardiovascular disease;
Diabetes mellitus;
Oesophagitis;
Gastric or peptic ulcers;
Renal or hepatic impairment;
Pheochromocytoma (a rare tumour of the adrenal glands);
Uncontrolled hyperthyroidism.

Nicotine mouth spray

Each metered dose of nicotine mouth spray delivers a fine spray of nicotine solution containing
1.0mg nicotine to the buccal mucosa (the inside lining of the cheeks).

Peak blood nicotine levels of 7ng/ml are reached within 16 minutes of administration of the 2mg
dose.
Smokers should be advised to use the mouth spray frequently. The recommended use is one to
two sprays every 30 - 60 minutes (maximum 4 sprays per hour and 64 sprays per day) in order to
achieve therapeutic levels of nicotine.
The smoker will get used to the aversive effects of the mouth spray with regular use.
Irritation to the mouth and throat is commonly experienced for the first few days
The bottle will need re-priming if unused for two days, refer to SPC for more information.

Nicotine mouth spray side effects

Common side effects are:
Hiccups;
Dysgeusia (distortions of taste),
Headache;
Indigestion;
Nausea.
These side effects become less severe with continued use.
Patients should be advised that the mouth spray is often unpleasant to use at first, causing an
irritation to the mouth and throat, but that this usually passes and people get used to it.
Warning smokers of the initial effects of the spray beforehand and getting them to practise using it
before their quit date can be helpful
Nicotine mouth spray cautions and contraindications
The nicotine mouth spray is contraindicated in those with hypersensitivity to any component of the
mouth spray, and children under the age of 12.
The nicotine mouth spray should be used with caution in smokers with:
Cardiovascular disease;
Diabetes mellitus;
Oesophagitis;
Gastric or peptic ulcers;
Renal or hepatic impairment;
Pheochromocytoma (a rare tumour of the adrenal glands);
Uncontrolled hyperthyroidism.

Nicotine Inhalator
The inhalator is popular with some smokers because it mimics the action of smoking to some
extent, although the inhalation technique is very different.
Some people get a sore mouth or throat and find that the nicotine taste is unpleasant. However,
most people get used to this if they continue to use the inhalator regularly.
Nicotine Inhalator side effects
The common side effects associated with nicotine inhalator are:
Coughing;
Hiccups;
Indigestion;
Heartburn;
Stomach ache caused by swallowed nicotine
Nicotine Inhalator cautions and contraindications
The nicotine inhalator is contraindicated in those with hypersensitivity to any component of the
inhalator and children under the age of 12.
As with all oral NRT products, the nicotine inhalator should be used frequently throughout the day
and for at least 8 weeks from the quit date. If the client wants to continue using the inhalator
beyond 8 weeks this will reduce the risk of relapse.
The nicotine inhalator should be used with caution in:
Cardiovascular disease;
Diabetes mellitus;
Oesophagitis;
Gastric or peptic ulcers;
Renal or hepatic impairment;
Pheochromocytoma (a rare tumour of the adrenal glands);
Uncontrolled hyperthyroidism;
Chronic throat disease and bronchospastic disease.

Nicotine strips
Nicotine strips are mint flavoured oral films available in 2.5mg strength. Strips are placed on the
tongue and then allowed to dissolve, which takes about three minutes.
Many smokers find the taste more pallatable than other forms of oral NRT.
Recommended use is one film every 1-2 hours, up to 15 per day.

Nicotine strips side effects

The common side effects associated with nicotine strips are:
Nausea;
Indigestion;
Heartburn;
Stomach discomfort
Mouth discomfort.
Warning smokers of the initial effects of the strips beforehand, and getting them to practice using
them before their quit date can be helpful.
Nicotine strips cautions and contraindications
Nicotine strips are contraindicated in those with hypersensitivity to any component of the oral film
and children under the age of 12.
Nicotine strips should be used with caution in patients with:

Cardiovascular disease;
Diabetes mellitus;
Oesophagitis;
Gastric or peptic ulcers;
Renal or hepatic impairment;
Pheochromocytoma (a rare tumour of the adrenal glands);
Uncontrolled hyperthyroidism;
Chronic throat disease and bronchospastic disease.

Nasal spray
Each metered dose of the nasal spray delivers a fine spray of nicotine solution, delivering around
0.5mg of nicotine to the nasal mucosa, about half of which is absorbed.
The nasal spray should be used regularly "on the hour, every hour" throughout the day to maintain
blood-nicotine levels.
This can be supplemented as necessary when cravings occur.
Nicotine from the nasal spray is absorbed faster than with from any other NRT product and it is
quick to use.
These features mean the nasal spray is ideal for heavily dependent smokers who want quicker
relief from withdrawal symptoms.

Ideally treatment should continue for at least 8 weeks, although some smokers will need to use
NRT for longer.
Side effects
The nasal spray is often unpleasant to use at first, causing a burning or itching sensation in the
nose until people get used to it, and all clients thinking of using the nasal spray should be warned
about this.
Other common side effects associated with the nasal spray are:
Sneezing;
Coughing;
Eyes watering;
These side-effects become much less severe with continued use, and most smokers get used to
the aversive effects of the nasal spray with regular use.
Warning smokers of the initial effects of the spray beforehand, and getting them to practise using it
before their quit date, can be helpful.

Cautions and contraindications

The nicotine nasal spray is contraindicated in:
Those with hypersensitivity to any component of the nasal spray;
Children under the age of 12.

The nicotine nasal spray should be used with caution in smokers with:
Cardiovascular disease;
Diabetes mellitus;
Oesophagitis;
Gastric or peptic ulcers
Renal of hepatic impairment
Pheochromocytoma (a rare tumour of the adrenal glands)
Uncontrolled hyperthyroidism;
Bronchial asthma.
Please refer to the summary of product characteristics (SPC) for a full description.

Varenicline (Champix)

Varenicline's brand name in the UK is Champix (Chantix in the USA) and it is a nicotinic
acetylcholine receptor partial agonist.
It was licensed for use in England in 2006 and is available on prescription only.
Compared to placebo varenicline has been shown to more than double long-term abstinence rates.
Clinical trials indicate that varenicline is almost twice as effective as bupropion and is almost
certainly more effective than single forms of NRT.
How it works
Varenicline reduces the desire to smoke by acting on the same receptors in the brain as nicotine,
and results in a moderate amount of release of the reward chemical dopamine (but not as much
as with cigarettes).
Varenicline also binds to nicotinic receptors in the brain, blocking the ability of nicotine from
cigarettes to stimulate these receptors. This is why many smokers using varenicline do not feel
satisfied if they have a cigarette.
Varenicline increases the chance of abstinence by reducing cravings, withdrawal symptoms and
smoking satisfaction.
Correct use
Smokers need to start using varenicline at least 7 days (and up to 14 days) before their quit day.
Smokers should be treated with varenicline for 12 weeks; for patients who feel the need for further
treatment an additional 12 weeks course of varenicline (1mg twice daily) should be made available.
Varenicline side effects
The most common reported side effects of varenicline are:
Nausea - about one third of smokers using varenicline experience nausea but for most (about
95%) it is mild to moderate;
Headache;
Difficulty sleeping (insomnia);
Abnormal dreams.
In general when adverse reactions do occur the onset is in the first week of treatment and most
resolve with time. Nausea can be reduced by taking the medication with food.
However, clients who cannot tolerate adverse effects of varenicline may have the dose lowered
temporarily or permanently to 0.5 mg twice daily.
There is no evidence to suggest that taking varenicline increases suicidal ideation, suicide
attempts or cardiac events.
Varenicline: cautions and contraindications
Varenicline is contraindicated in people with an allergy to varenicline and:
Children and adolescents under 18;
Pregnancy;

Breastfeeding;
Cautions
Varenicline should be used with caution for those with:
Decreased kidney function;
History of, or current, psychiatric illness (major depressive disorder, bi-polar disorder,
schizophrenia);
Epilepsy.
In instances where a client forgets to take a tablet, they should be advised to take their next tablet
as normal and to not miss any more.
Other treatments
It is useful to have some knowledge of the other treatments that smokers may try, or consider
using alongside or instead of, the behavioural support and medication you are able to offer.
Bupropion (Zyban)
Bupropion is also known as Zyban.
It is an atypical antidepressant that was also found to help people stop smoking and was licensed
for use in England in 2000 and is available on prescription only.
Exactly how buproprion aids smoking cessation is unknown. It is thought to act via its ability to
inhibit the neuronal reuptake of dopamine and noradrenaline, both important in nicotine
dependence and withdrawal.
Bupropion acts to reduce the severity of withdrawal symptoms and by reducing the desire to
smoke.
Correct Use
Smokers need to start using bupropion at least 7 days (and up to 14 days) before their quit date.
The standard regime involves:
One tablet (150mg) daily for the first 6 days;
From day 7 onwards smokers take one tablet twice daily (with at least 8 hours between doses).
The standard course is for 120 tablets (between 7-9 weeks)
Efficacy
Compared to placebo bupropion approximately doubles long-term abstinence rates and so has
similar efficacy to single-dose NRT.
There is insufficient evidence to determine if bupropion is superior to NRT but three studies have
shown that bupropion has lower efficacy than varenicline.
There does not appear to be any benefit of adding NRT to bupropion.

Side effects
The most common side effects of bupropion are:
Dry mouth;
Insomnia;
Headache.
There is also a low risk of seizures. Bupropion lowers the seizure threshold and seizures have
been reported, although the risk of seizure (about 1 in 1000) is similar to other antidepressants.
Some users can also experience urticaria (skin rash).
Cautions and contraindications
Buproprion is contraindicated in patients with:
Current seizure disorder or any history of seizures;
Abrupt alcohol or sedative withdrawal;
Use of irreversible monoamine oxidase inhibitors;
Bulimia, anorexia nervosa (or history of);
Severe hepatic cirrhosis.
Cautions
Buproprion should be used with extreme caution in smokers with severe liver disease or renal
impairment. Reduced dosing is recommended for this patient group.
Caution should be exercised where there is predisposing risk factors for seizures, which include:
Use of other medicines known to lower seizure threshold;
Excessive use of alcohol or sedatives;
History of head trauma;
Diabetes treated with hypoglycaemics or insulin;
Use of stimulants or anorectic products.

Electronic cigarettes
There are new products entering the market and it is important to understand the current state of
regulation for these products.
Electronic nicotine delivery devices, commonly referred to as 'e-cigarettes', are becoming
increasingly popular with smokers.

In 2013 the MHRA announced its intention to regulate these products as medicines. However,
existing models are not required to obtain a medicine licence until the proposal in the European
Commissions revised Tobacco Products Directive is agreed (circa 2014) and transposed into law
(circa 2016).
Until licensed, the effectiveness and quality of e-cigarettes is unknown and these products are not
available on the NHS.
Clients who attend a stop smoking service and wish to use an e-cigarette can still be supported,
but should be encouraged to use a licensed stop smoking medication as well.
Ineffective treatments
There are a number of other treatments and approaches that have been studied and shown to be
no better than placebo in helping people quit smoking.
Some smokers will have quit whilst using one of these other treatments but it is unlikely to have
been the treatment that helped with the quit attempt, they might just have quit anyway (like some
people do 'cold turkey').
Other medications
There are a number of other 'medications' and products that are marketed as helping smokers to
quit and smokers will often ask about them.
However, these products are not actually considered to be medicines and so are not subject to the
rigorous evaluation and safety criteria that medications are (hence their rather exaggerated claims
of efficacy).
These medications and products are not licensed for smoking cessation and should not be
recommended.
Other methods, such as hypnotherapy and acupuncture, claim to help smokers stop smoking.
However, these methods are not supported by clinical research and smokers should know that
their best chance of success is through the use of licensed medications with the support of stop
smoking services.
Hypnotherapy
Hypnotherapy is popular among smokers wanting to quit, but has not been found to have any
specific beneficial effect.
People may have quit smoking while undergoing hypnotherapy, but the percentage who remain
smoke free is no greater than those who go 'cold turkey' without any support.
Other 'complimentary therapies'
Acupuncture, acupressure, laser therapy, and electrostimulation for smoking cessation have been
researched but have not been found to have any effect.
Of course some ex-smokers may believe that these therapies can help reduce nicotine withdrawal
symptoms.

You can tell smokers that there is no evidence supporting the use of these techniques in smoking
cessation, and advise them to use evidence-based medication, and seek support from a stop
smoking service.
Introduction to the practice section

Stop smoking behavioural support programmes have been extensively evaluated and the
interventions that increase effectiveness and long term quit rates are known.
This section of the course explains how to use the knowledge you have gained to plan and deliver
effective behavioural support.
There are a number of video clips you can watch in which Professor Robert West explains the role
of each behaviour change technique and then a short film demonstrates how they can be delivered
effectively.

Smokers who need additional support

Some smokers are more likely to quit than others, and greater support is needed for smokers who
are at higher risk of lapse and relapse following their quit date.
Knowing the characteristics of the smokers you see can help you to tailor the behavioural support
programme to meet their needs, as well as assessing your own level of performance and that of
your service.
Smokers are more likely to relapse to smoking if they:
Are younger;
Smoke first thing on waking, or they interrupt their sleep to smoke (i.e. are more dependent);
Have a partner who smokes or they live with people who smoke;
Come from a low paid manual job or are unemployed;
Have a mental health problem or illness;
Are drug or alcohol dependent.
Making a clear commitment to the personal rule of 'not a puff, no matter what', is also important in
preventing lapse and relapse.
The process of quitting
Stopping smoking involves making a quit attempt and sticking with it.
Evidence clearly shows that different factors are involved in these two stages.
Smokers make a quit attempt when their concerns about smoking, usually because of health
worries or cost, overpower their feeling of attraction to smoking.

This desire to stop can happen at any time and studies have found that half of quit attempts are
made without any pre-planning at all.
However, the main barrier cited by smokers to making a quit attempt is their perceived enjoyment
of smoking.

The 'stages of change' and smoking

The well-known model of behaviour change known as the 'Stages of Change' or 'Transtheoretical'
model incorrectly states that people have to move through a stage of 'contemplation' before they
get to the quit attempt.
Evidence shows that even people who were not intending to stop smoking will accept the offer of
help and can go on to succeed.
Stopping smoking
Powerful urges to smoke start very soon after quitting. In some cases these can feel as if they are
constant, while in other cases they are linked to particular situations or cues.
The smoker can also start to feel low and that life lacks enjoyment (one of the withdrawal
symptoms); this can quickly lead to a lapse.
The only thing stopping the person from having a cigarette is a strong emotional commitment to the
not a puff rule, and the anticipated feeling of guilt, shame or personal let-down that would
accompany smoking again.
Avoiding, minimising and resisting the urges to smoke is one of smokers' most important tasks in
the first few weeks after the quit date.
Your job is to use your skills and knowledge to help smokers minimise their exposure to urges to
smoke, and to resist them when they arise.
As the weeks pass, the need to smoke usually lessens and the mental strength needed to resist it
reduces.
However, there will often be flare-ups in cravings, particularly (but not always) around stressful
events, holidays, or celebrations. These can lead people to smoke as they give themselves a
temporary exemption or 'excuse' to smoke.
In these situations, commitment to the new identity of the ex-smoker is important.
Smokers need to be forewarned about the pitfalls they face once they think they are out of the
woods, and to make sure they have the psychological and practical resources (such as
medication) needed to face these cravings when they happen.
Biomarkers for smoking
Biomarkers are biological measures of smoke intake, or its consequences on physiological
systems.
They can be important in providing more accurate information on smoke intake than you can get
from cigarettes per day because people differ in how hard they smoke each cigarette.

They are also potentially useful in motivating smokers to become and remain abstinent, and
confirming claims of abstinence.
The two main biomarkers in use are expired air carbon monoxide (CO), and saliva cotinine.
Expired-air Carbon Monoxide (CO)
CO is the standard biomarker for smoking in clinical practice, and all stop smoking specialists
should all use a CO monitor routinely.
CO monitoring is an essential tool, and it is vital to know how to measure it accurately and discuss
the results with smokers.
Carbon Monoxide is a good measure of smoke intake on the day, but will not usually detect
smoking the day before.
It will also typically be lower in the morning than afternoon because levels build up over the course
of the day.
The standard cut-off for detecting smoking is 10 parts per million (ppm) but in practice it is rare to
see levels above 5ppm in non-smokers.

Cotinine
Cotinine is a metabolite of nicotine that is eliminated from the body more slowly than nicotine.
Cotinine is usually measured in saliva but can be usefully measured in urine and blood as well.
It is easy to collect saliva using cotton dental rolls, but these have to be sent off for laboratory
analysis.
It is by far the most accurate measure of smoke intake that we have and works very well for
detecting exposure to environmental tobacco smoke, but it cannot distinguish between smoking
and NRT use.
Cotinine lasts for several days in the body so is better than CO at detecting intermittent or low
levels of smoking; the optimal cut-off for detecting smoking is 13ng/ml.
There are occasions when it is useful to measure cotinine in clinical practice, such as in pregnancy.
Practice: pre-quit
The pre-quit session(s) set the foundations upon which you will build the quit attempt with your
client.
There are a number of relationship building, assessment, and information giving tasks that need to
be undertaken and these are described on the following pages.

Build rapport

It is essential that you develop a rapport with your client. The positive relationship you establish
with the smoker must be one that is professional, friendly, and supportive.

Smokers must not feel that you are judgemental or telling them off. It is essential to show the
smoker a high level of respect in the way you address them and in your body language.
You need to show that you have heard and understood what smokers are telling you by responding
specifically and appropriately to what they say.
Ask things like:
'How are you feeling about your quit attempt now given our discussions about the coming week?'
'Are there any questions that you have about what we have discussed or about what you are going
to be doing this coming week?'
Encourage the smoker to speak openly and to answer your questions honestly. Resist the
temptation to gives lots of advice and instead try and encourage clients to come up with their own
coping strategies and solutions.
Building rapport with the smoker is essential and is an ongoing process throughout the behavioural
support programme. The smokers must trust you as a professional, know that you show him or her
respect and most of all they must want to come back to see you to tell you that they have not
smoked.
It is important that you can judge how confident, motivated and prepared the smoker is for the
coming week so that you can tailor your interaction with them appropriately.
Reflective listening allows you to ensure that the smoker has understood the information you have
provided and what is expected of them during the quit attempt.
When informing the smoker that they are increasing their chances of stopping smoking for good by
receiving behavioural support and medication, you could say something like:
'You have taken an important first step by coming along to see me. Research has shown that
people who get support and use a stop smoking medication are far more likely to stop and stay
stopped than those who try to quit on their own.'
When explaining to the smoker that weekly contact with you is extremely important, you could say
something like:
'You will need to see me for six sessions over six weeks, once before quitting, once on your quit
day, and then once a week for four weeks after your quit date.

Listen to your client's views

There is no 'one style fits all' treatment for smokers wanting to quit. It is likely that the behavioural
support programme, and medication choice and use will all need to be tailored to each client's
circumstances.
It is also important to let the client speak so that you can check that they have understood what
you have discussed and to find out how they are feeling about their quit attempt.

Explain the role of services

It is important that you inform smokers of the value of using a service by telling them that they are
up to four times more likely to succeed with the help of a stop smoking services (providing
evidence-based behavioural support and effective medications) than they would be if they try to
quit unaided.
When informing the smoker that they are increasing their chances of stopping smoking for good by
receiving behavioural support and medication, you could say something like:
'You have taken an important first step by coming along to see me. Research has shown that
people who get support and use a stop smoking medication are far more likely to stop and stay
stopped than those who try to quit on their own.'
Explain that this increased chance of success is because of a combination of:
Regular support for at least six weeks;
Help and advice about medication choice and correct use;
Commitment to a quit date;
Accurate information about what to expect during the quit attempt and how to deal with difficult
situations;
Explain the weekly session schedule
Weekly contact is extremely important, in fact the more contact with you the better their chances of
success are. Explain to clients that they will need to see you for at least six sessions:
Once before quitting;
Once on the quit day;
Once a week for at least four weeks after the quit date.
It is essential that clients make a clear, firm, verbal commitment to coming to every session. You
should explain that a check will be made on progress using a simple carbon monoxide breath test
at every visit as this can be highly motivational.

Explain the importance of the programme

Having explained the role of services and medication, it is also important to reinforce to the client
how much they will need to commit to the programme in order to maximise the chances of
success.

Explain how tobacco dependence develops

Explain to clients that the reasons for continuing to smoke are different from the reasons for
starting to smoke, and link this to their current and past smoking behaviour.
Most people, when they first start smoking, do so intermittently and feel that they can take it or
leave it. However, because of physical changes to the brain smokers soon become used to regular
doses of nicotine and smoking becomes less about choice and enjoyment and more about needing
to smoke.
You can point out to smokers that they probably had a different view of smoking cigarettes when
they first started, than they do now.
This is partly because over time they have become dependent upon the nicotine in cigarettes.
Reinforcing the nature of nicotine dependence gives the smoker an understanding of why they
smoke and a realistic expectation of what their quit attempt will involve.
Assess current and past smoking behaviour

Understanding your client's current and past smoking, including their history of quit attempts, is an
essential component of the assessment process.
Smokers will expect you to ask them about this and it is a good way of starting the assessment.
There are a number of questions that you can ask that will allow you to understand their smoking
history such as:
When did you first start smoking?
How many cigarettes a day do you usually smoke?
What do you smoke and where do you buy them?
Although covered in more detail later, assessing the number of cigarettes they smoke a day is
another question that smokers will expect and it may give you an early indication of what level of
support they might need.
History of quit attempts

You should ask all clients if they have made a serious attempt to stop smoking before. It is useful
to find out whether the smoker has any past experience that they can draw upon for their current
quit attempt.
It is also helpful to discover their attitude towards medication use, and to ensure that they have a
realistic expectation of what medication use can add to a quit attempt.
If they have made a quit attempt in the past, find out:

How many serious attempts to stop smoking they have made;

What is the longest time they have successfully stopped smoking for in the past;
If they have ever used any medication to help with a quit attempt in the past.
If the answer to the medication question is 'yes' it is essential to find out which medication(s) they
have used before, and to understand their experience of the medication. A typical question to
assess this would be:
'What medication have you used and how did you get on with it?'
If the person you are assessing hasn't made a quit attempt before, you can congratulate them on
making the best decision by coming to see you and giving themselves the best chances of
success.

Assess readiness and ability to quit

Getting the smoker to make a commitment to quit smoking both to themselves, and to you, should
boost their motivation.
A smoker's confidence in ability to stop does not generally predict success, so smokers who
express low confidence can be reassured that this will not hinder their chances.
It is however important that the smoker has clear expectations of what the behavioural support
programme involves and commits to engaging with it, including attending every session.
It can be useful to define the current quit attempt as a serious one (made with the aid of effective
medication and expert behavioural support) and to distinguish this from previous ones if it is
appropriate to do so.
If the smoker does not feel that they are ready to make a serious attempt to quit and decides not to
continue with the programme, make sure that they have your service's contact details and ask
them to get in touch with you when they are ready.
To assess readiness to quit you can ask questions such as:
Can I check that you want to stop smoking altogether and are willing to put in the effort required?
'How confident are you that you will be able to succeed this time?'
Further exploration of the issues
You can further explore their readiness and ability to quit by asking:
'If it is OK with you, I would like to quickly ask you about your smoking, and past attempts to stop
smoking, so that I can work out how best to help you with this quit attempt;
'When did you start smoking?'
'How many times have you tried to quit smoking before?'

'Can I ask you whether you are ready to stop smoking for good?' This question can give you a
useful sense of whether the smoker is nervous or ambivalent. If they are, you can offer
reassurance:
'You sound a little nervous about stopping smoking which is completely understandable, and very
common. The good news is that by getting support from trained professionals such as me, and by
using effective medications, you are greatly improving your chances of success.'
If the smoker sounds positive this offers an opportunity to reinforce their commitment:
'It's great that you are sounding so positive about stopping smoking: motivation to quit successfully
is really important.'
If they haven't made a serious quit attempt you can be positive about this:
'It's great that for your first quit attempt you have chosen to maximise your chances of success by
getting help. Lets see if we can make sure your first quit attempt is also your last.'
If they have a history with multiple quit attempts you can say:
'Having tried to quit and failed, but then tried again, shows what commitment you obviously have to
stopping smoking. Many smokers take a number of quit attempts before they quit for good, and
each of your previous attempts can be used to help with this one.'
Anyone who has gone several weeks or months without smoking will have experienced the
withdrawal symptoms getting less severe and frequent. Smokers who have managed only a few
days of abstinence will not have experienced this, and may not have had the experience of
overcoming urges to smoke. So it is important to ask anyone who has tried to quit before:
'What is the longest time that you have gone without smoking?'
For smokers who have never tried to quit before this may only be for a day or so, or even less but
you should still be positive about this:
'Even that period of time is some achievement for regular smokers, how did you manage it?' ......
'Well with your motivation to stop, and with use of medication this can be built on this time.'
For longer periods of weeks or months you can be even more positive:
'That is very impressive. How did you manage to not smoke for so long; are there any strategies
that you would use for this quit attempt?'
Assessing past use of medication
It is important to understand past use of stop smoking medications, as answers to this question will
allow you to assess whether the smoker has used medication properly in the past, and what
expectations they have of the medication.

Assess physiological and mental functioning

Knowing how well smokers can function, both physically and mentally, will allow you to plan an
appropriate behavioural support programme and to assist them with their choice of medication.
There are some medications whose dose will need monitoring and possibly adjusting when the
smoker stops smoking (see 'effect of smoking cessation on other medications' in the medications
overview).

Ask whether the smoker has any physical condition that may affect their quit attempt with a
question like:
'Do you suffer from any physical illness or disorder?'
Ask whether the smoker has any mental health condition that may affect their quit attempt with a
question like:
Do you suffer from any mental health problem such as depression, stress or any psychotic
disorder?

Assess nicotine addiction

Assessing clients' nicotine addiction to find out their level of dependence helps provide them with
an understanding of what they need to overcome and will inform the behavioural support
programme and medication choice.
Inform the smoker about the nature of nicotine dependence and how it develops using phrases
like:
'When you first start smoking regularly your brain changes so that it expects regular doses of
nicotine. This need for nicotine from cigarettes can undermine your motivation to stop smoking,
especially when linked to the temporary withdrawal symptoms smokers can experience at first
when they do not smoke.'
Reassure your client that with use of proven medications and effective support they will have a
good chance of overcoming their nicotine addiction.
Ask the smoker:
'How many cigarettes per day do you smoke?'
'How soon after waking do you have your first cigarette of the day?'
You could also conduct the full Fagerstrm Test for Nicotine Dependence (FTND).
Assess social support

To ensure that smokers recognise the importance of support throughout the quit attempt, and that
they are aware of the danger of being exposed to cigarettes and to smokers, you must outline the
importance of appropriate support to a quit attempt.
Usually this will involve delivering an intervention such as:
'There are going to be times during your quit attempt, especially in the first few weeks, where the
support and encouragement of friends, family and colleagues is going to be really helpful.'
Encourage clients to tell as many people as possible that they will be quitting smoking, and that
they are going to need their support.

Explore whether the smoker is likely to receive social support for their quit attempt and ask the
smoker if they have any family/friends who smoke.
This information will help clients to identify where support is needed and from whom, and will assist
you when planning the behavioural support programme.
Assess contacts who smoke

Being around people who smoke can be a significant contributing factor in relapse. Seeing other
people smoking can trigger urges to smoke and smokers provide access to cigarettes that can turn
an urge into a lapse.
Ask your client if they live with any smokers or spend long periods of time with smokers. If the
answer is yes, explain the dangers of exposure to cigarettes and smokers after the quit date.

Attitudes to smoking and stopping

Finding out what smokers' attitudes to smoking are, and identifying reasons for wanting or not
wanting to stop smoking is important.
Allowing clients to voice their reasons for wanting to stop smoking will help them, and you, arrive at
a clear understanding of their feelings about their quit attempt.
Ask the smoker
'For you, what are the most important reasons for smoking that you think will make it hard to stop?
This question gives an opportunity to address unhelpful beliefs about smoking, particularly that it
helps them cope with stress.
It doesn't, but smokers come to believe that it does, and as long as they do they will be motivated
to smoke when something stressful happens. Asking this question gives you a good opportunity to
counter this myth.
Allow the smoker to voice any concerns about stopping smoking by asking:
'What do you enjoy about smoking that you think you will miss the most when you quit?'
You can reinforce their motivation by asking:
'What is the main reason that brought you to try to quit now?'
When responding, emphasise the importance of the smokers reasons for wanting to stop smoking,
and explain that it is very common to have doubts and concerns.
It is important to emphasise the reasons for wanting to stop smoking to build the smokers
motivation and to reflect this back to them so that they have a sense that their experiences are
understood.

This question also provides something that you can remind them about later when the going gets
tough. You can say:
'When you first came to see me you said that X was why you particularly wanted to stop. Keep this
in your mind whenever you are tempted to smoke.'
If the smoker expresses high levels of doubt and concern about stopping smoking you can say:
'It sounds as if you enjoy smoking and there are things you will miss about it, which is completely
understandable and very common. Your reasons for wanting to stop seem very important to you,
and with effective medications and plenty of support and advice from me, I am confident I can help
you to stop smoking.'
If the smoker expresses few or no doubts or concerns you can say:
'Your reasons for wanting to stop smoking sound very powerful, and will help keep your motivation
high, which is important to stop smoking. Remember though that you can be overconfident - dont
place yourself in dangerous situations where the temptations will be strong, and practice strategies
for dealing with urges to smoke.'
Advise on environmental restructuring

Advising the smoker to avoid or minimise their exposure to cues (triggers) to smoke will reduce
their likelihood of lapse.
Advise the smoker to ensure that their house, workplace, and car are completely clear of:
Cigarettes;
Lighters;
Ashtrays.
Explain that this reduces their exposure to cues which could trigger urges to smoke.
Advise on changing routine

Ask the smoker to identify situations and activities in which they would previously have smoked
and explain that strong urges to smoke may be triggered at these times.
Explore ways that the smoker can avoid or limit their exposure to these situations, and encourage
the smoker to come up with their own solutions. This is important as they will be best placed to
come up with potential solutions and are more likely to put them in place.
Examples of things ex-smokers typically found useful to change while stopping smoking include:
Where they sit;
Where they go for breaks;
Their route to work;

What they do after meals;

Their morning routine.
Advise on the use of social support

The support of friends, family and colleagues will boost smokers motivation to succeed in their quit
attempt.
Stopping smoking can be difficult, and most quitters appreciate the encouragement and support of
friends, family and colleagues.
Advise the smoker to inform as many people as possible that they are quitting; the enquiries as to
how they are getting on, and the congratulations on their continued abstinence, will be helpful.
Prompt self-recording
Prior to the quit date ask the smoker to consider which cigarettes they think they will miss the most
and in which situations they think it will be hardest for them not to smoke.
Ask them to identify friends, family and colleagues who will be able to offer support as well as any
contacts who smoke and might therefore pose a threat to their quit attempt.
It is important that the smoker is aware of any potential barriers to their quit attempt as well as the
support that is available to them.
It is also important that the smoker takes 'ownership' of their quit attempt
Explain that the nature of stopping smoking means that there are going to be times after the quit
date when they really want a cigarette. Advise them that:
'Experience tells us that it is worth having a few strategies to deal with these times when you
experience strong urges to smoke.'
Allow the smoker to come up with some ideas that you can expand on if necessary.
If the client is struggling to think of strategies for themselves you can offer some suggestions as
part of a menu of options. Such options may include:
Ensure that cigarettes are not available;
Ensure proper use of medication;
Distraction;
Short period of exercise;
Remind of motivations to quit;
Imagining telling people you have started smoking again;
Imagining going through this again in the future.

Explain the importance of Carbon Monoxide monitoring

Explain to your clients that carbon monoxide (CO) is a poisonous gas contained in cigarette
smoke, and that there is a simple test that can be carried out to determine CO levels.
Inform the smoker that you will conduct this test at every appointment and that their CO levels
should drop to that of a non-smoker by the appointment after their quit date - as long as they do
not smoke at all.
Explain that the CO test is carried out to provide the client with 'proof' that their health is benefiting
from quitting, and so that you can check on whether they have been smoking or not.

Facilitate medication choice

Supporting the use of stop smoking medications involves:
Advising clients of the effectiveness and safety of stop smoking medications;
Describing what medications are available;
Assessing any cautions and contraindications;
Discussing any side effects (and how to deal with them);
Ensuring that clients have a realistic expectations of the medication;
Helping clients to choose their medication;
Assisting with obtaining their chosen medication;
Reminding clients of the importance of behavioural support to their quit attempt.

Advise on stop smoking medication

Advise the smoker that stop smoking medications are an aid to their quit attempt and will not
completely get rid of the desire to have a cigarette.
They are not a 'magic bullet'.
Confirm what medication the smoker is using, and make sure that they have a sufficient supply,
make sure that you address any concerns the smoker may have and ensure that they are happy
with their choice.
In the case of bupropion and varenicline ensure that the smoker will have been using it for at least
one week before their quit date, and enquire as to any effects from the medication and any side
effects.
For those using NRT get them to bring it with them on their quit so that they can begin to use it
during the session.
Describe contraindications, cautions, and side effects

Describe the contraindications for the smokers preferred medication to ensure that they are able
to use it.
Describe the cautions for the smokers preferred medication to allow a judgement to be made as to
whether using this medication is appropriate or whether an alternative should be sought.
Delivering these interventions will ensure that the smoker is:
Safe to take their medication of choice;
Aware of any potential side effects;
Able to use their medication as effectively as possible;
Some clients are concerned that they will become addicted to NRT. You can reassure them that
this is not common, and that it should definitely not be their concern at the beginning of their quit
attempt, as the biggest problem with NRT is that people do not use enough of it for long enough.
NRT contains therapeutic nicotine without the tar and carbon monoxide contained in cigarette
smoke; so even if they were to use it long term it would be safe.
Continued NRT use, and any concerns that clients have about their medication, can be dealt with
at the end of the behavioural support programme.

Explain the importance of the 'not a puff' rule'

The temptation to have 'just one' cigarette can be extremely powerful, but the thought that it can be
just one and that it will not lead back to regular smoking has been shown to be one of the key
predictors of relapse.
It is therefore crucial to reinforce the message to clients that stopping smoking with your help
involves a rule of not smoking even one puff on a cigarette after their quit date.
It may make sense to some smokers to cut down the number of cigarettes that they smoke each
day rather than quitting abruptly, or even quitting at all. Unfortunately cutting down doesnt work as
smokers almost inevitably end up smoking the same number of cigarettes as they did previously.
Even if they do manage to genuinely reduce the number of cigarettes that they smoke their mind
and body will crave similar amounts of nicotine from these fewer cigarettes. This leads them to
subconsciously smoke these fewer cigarettes more efficiently by taking more puffs, holding the
smoke in their lungs longer and smoking the cigarette closer to the filter.
Unless clients are using NRT to help them cut down prior to quitting they will get similar amounts of
nicotine from these fewer cigarettes, and therefore similar amounts of tar and carbon monoxide.
There is therefore no health benefits of cutting down, or switching to lighter cigarettes, and this is
known as compensatory smoking.

Set a quit date

Explain the importance of setting a quit date (after which they will not smoke even one puff on a
cigarette) and sticking to it:
'It is important that we agree a quit date after which you do not smoke at all'
The quit date should be far enough in advance to allow the smoker to obtain their medication and,
in the case of varenicline, bupropion and NRT preloading, to begin taking it.
Those smokers using varenicline, bupropion or NRT preloading may also need a further pre-quit
session.
For those smokers quitting as part of a rolling behavioural support programme there may need to
be some discussion about the quit date.
Explain that ideally smokers will have their last cigarette immediately before their quit date session
and should throw away any remaining cigarettes, ashtrays and lighters.
It is important to emphasise the not a puff rule.
For example, you might find it useful to say:
'Many smokers find that without a definite quit date they never quite get around to making that
attempt to stop smoking. Setting a quit date too far into the future can have a similar effect. You
need to decide upon a quit date that gives you enough time to get hold of the medication that you
are going to use and gives you the best chance of getting through that first day and week.'
Explain that stopping smoking with your help involves a rule of not smoking even one puff after
their quit date.
If there is resistance or lack of commitment to a quit date, you should explain that cutting down
gradually, unless done with NRT as part of a planned programme, is not an effective approach to
stopping smoking.
'The problem with trying to stop by cutting down gradually is that it can end up being so gradual
that the smoker never actually stops. The only real way of stopping smoking is to stop abruptly.
This allows your body to begin to adjust to not smoking and you to adjust to life without cigarettes'

Summarise information given

As well as summarising the client choices, it is important to provide the client with a summary of
the information you have given.

Practice: quit date

Clients can often be very nervous on their quit date: nervous that they will not be successful in
stopping smoking, or nervous that life will not be the same without cigarettes if they are.
Your role is to boost clients' motivation and to ensure that they have everything in place to give
themselves the best possible chance of quitting.

This section of the course takes you through the key elements of the quit date session. The video
clips explain the rationale for each intervention and give a demonstration of how they can be
delivered.
Prompt commitment

It is important that the smoker hears themselves commit to not smoking there and then, while they
are with you.
Ask the smoker whether they have had their last cigarette yet and, if not, to confirm what time
today it will be. Ask them to tell you that they will commit to not having a cigarette, not a puff, after
this time.
Get the smoker to say, out loud:
'I am going to stop smoking, and not have even one puff on a cigarette starting now'
This contributes to the building of rapport, leaves no room for misunderstanding as to the aim of
the quit attempt and is an important psychological tool that cements the smoker's decision to quit.
If the smoker says that they are considering putting off their quit date say:
'If you really do not feel that you are ready to stop smoking then you should wait... stopping
smoking takes a lot of determination, and works best if you are 100% ready to quit... however,
there is never really a good time to stop smoking and you should not continually postpone
stopping smoking by waiting for the 'right time'.'

Facilitate medication use

Effective use of medication is key to any successful quit attempt and you have an important role to
play in this by:
Confirming what medication the smoker is using and making sure that they have a sufficient
supply;
Ensuring that the client has a realistic expectation of how the medication can help their quit
attempt;
Making sure that the client is using enough of their medication and is using it properly;
Monitoring any side effects and advising on dealing with these.
Advise on stop smoking medication
Confirm what medication the smoker is using and, in the case of varenicline and bupropion, that
they have been taking it for at least one week. Clients using NRT should have brought this along
with them.
Make sure that they have a sufficient supply, and certainly enough medication until their next
appointment with you.
Remind the smoker that stop smoking medications are an aid to their quit attempt and will not
completely get rid of the desire to have a cigarette.

Varenicline and bupropion

In the case of varenicline and bupropion enquire as to any effects from the medication and any
side effects.
Ask the smoker if they have suffered from any out of the ordinary physical or mental symptoms
since taking their medication, and help the smoker to distinguish between medication side effects,
withdrawal symptoms and unrelated symptoms.
Inform the smoker that in many cases people get used to the side effects of stop smoking
medications, or they become less severe, as they continue to use them.
Discuss ways of dealing with the side effects such as taking varenicline with food, reducing dose,
taking a remedy for the side effects, and assess whether the smoker is able to continue to use the
medication properly despite the side effects.
If the smoker experiences a serious adverse reaction you must report this immediately to the stop
smoking manager, make a record of it in their notes, and advise them to see their GP.
Nicotine replacement therapy (NRT)
For those clients using NRT get them to start using their chosen product or products right away.
This allows you to:
Instruct clients on the correct usage and dosage of their NRT;
Explain the possible side effects of their medication (including bad taste for the oral products) and
how these can be dealt with;
Inform the smoker that in most cases people get used to the side effects of NRT (including taste)
within 48 hours if they continue to use them properly;
Remind the smoker of the importance of optimum medication use to reduce withdrawal symptoms
and urges to smoke as this will give them the best chance of quitting.

Delivering these interventions will ensure that the smoker is:

Safe to take their medication of choice;
Aware of any potential side effects;
Reassured about any symptoms that they might be experiencing;
Able to use their medication as effectively as possible;
Able to minimise any adverse drug effects.

Maximise motivation to quit

A crucial active ingredient of behavioural support is boosting the smokers resolve to stay off
cigarettes.
This can be done in any number of ways but your relationship with your clients, and getting them to
want to come back and see you and tell you how well they have done, is particularly important.

Giving information about the harm caused by smoking can help to reinforce the smoker's decision
to quit and boost their motivation not to smoke after their quit date. It is particularly important to
reinforce the 'not a puff' rule because reinforcing the importance of stopping smoking completely
can help focus the smokers attention on the effort required.
Provide information on the consequences of smoking and smoking cessation
Explain the consequences of continued smoking and the urgency of stopping now by saying:
'As you probably know stopping smoking is the single most important thing that you can do for your
current and future health.'
'Smokers not only die younger than non-smokers but suffer more disability and ill-health. Every
year you put off smoking after the age of 35 results in a loss of 3 months of life on average and for
many smokers it is much worse!'
You can help clients to distinguish between the harms from smoking and nicotine by saying:
'It is worth remembering that although it is the nicotine in cigarettes that is addictive and keeps you
smoking, it is the tar, carbon monoxide and other substances in tobacco smoke that cause harm.'
You can reinforce to clients that stopping smoking completely is the only way of guaranteeing
health benefits:
'Because your mind and body are used to a certain amount of nicotine, switching to lighter
cigarettes, or trying to reduce the number of cigarettes that you smoke doesn't really work. The
result is that you will smoke those lighter cigarettes or reduced number of cigarettes more
efficiently to make sure that you get the nicotine from them that you are used to. Similar amounts
of nicotine mean similar amounts of tar and carbon monoxide and similar health risks.

Measure carbon monoxide (CO)

Outlining the role of carbon monoxide (CO) monitoring in verifying smoking status, and in showing
the client how quickly their CO readings can return to that of a non-smoker, can help to boost their
motivation.
To ensure the accuracy of carbon monoxide measurements, you must ensure that the CO test is
carried out properly. You must also ensure that your CO monitor is calibrated and stored according
to the manufacturer's instructions.
For clients who struggle to hold their breath, such as those with chronic obstructive pulmonary
disease (COPD), then holding their breath for 10 seconds prior to the CO test (but no less than
this) is sufficient.
The most accurate result
Advise on withdrawal symptoms
Providing smokers with a realistic expectation of what the withdrawal symptoms are, and what they
can be like, will mean that they will be better prepared.
This means describing common withdrawal symptoms and urges to smoke that clients are likely to
experience after their quit date.

Explain that the problems experienced by more than half of smokers who stop are:
Urges to smoke or cravings (usually reduce over time as long as clients do not smoke, but can
appear for a long time after quitting);
Increased appetite, and weight gain (can persist for three months or longer);
Depression;
Restlessness;
Poor Concentration;
Irritability/Aggression.
If it is appropriate you can mention the other less common withdrawal symptoms:
Light-headedness (usually lasts less than 48 hours);
Waking at night (usually lasts for less than a week);
Mouth ulcers (can last over a month);
Constipation (can last over a month).
Also explain that withdrawal symptoms are temporary. Most of them reduce as time goes by, and
disappear completely by four weeks after the quit date, as long as the client does not smoke.
You should reinforce that proper use of medication is the most effective way of reducing withdrawal
symptoms and urges to smoke.
It is important to find out whether the smoker has any past experience that they can draw upon for
their current quit attempt.
What you need to do
You should inform the smoker of the likelihood of experiencing withdrawal symptoms and explain
what these are and why they occur, saying something like:
'Because your body is used to regular doses of nicotine, it has to adjust to being without it (or
having much less of it if you are using NRT). Within the first few hours of stopping smoking your
body will start getting used to life without nicotine this adjustment results in withdrawal
symptoms.
Ask the smoker whether they have experienced any withdrawal symptoms during previous quit
attempts by saying:
When you have stopped smoking before, or have had to go without a cigarette for a long time, did
you notice any symptoms that came on... was there anything that worked for you in dealing with
these that could be useful this time?
Respond appropriately reinforcing that this knowledge is going to be helpful during this quit
attempt.s are gained when clients hold their breath for at least 15 seconds.

Advise on weight gain

Inform the client that smokers often put on weight after quitting because nicotine increases
metabolic rate (more calories are burned when smoking) and nicotine also acts to slightly reduce
appetite.
A review of 62 studies revealed that smokers not receiving treatment typically put on an average of
1.12kg (2.5lbs) one month after their quit date and 4.67kg (10.3lbs) at 12 months.
For those smokers concerned that putting on weight will put them off continuing with their quit
attempt, you can discuss ways of minimising weight gain such as taking more exercise, and
carrying around healthy, low calorie snacks.
It is important to allow smokers who are concerned about weight gain to put in place strategies to
minimise this that do not interfere with their quit attempt.
The recommended approach for smokers who are concerned about weight gain after quitting is to
concentrate on stopping smoking, as this is the one thing that is going to have the biggest impact
on health, and for the majority of people it is best to undertake just one major health behaviour
change at a time.
If smokers try to quit, change diet and increase the amount of physical activity at the same time
they may end up failing in all three.
If the client has successfully stopped smoking for a couple of months and they are feeling confident
they are an ex-smoker, they could then look at changing their diet and exercising more.

Alcohol and caffeine

There are relapse risks associated with alcohol and coffee and a discussion with clients about
these can help them to plan to avoid or reduce these risks.
Inform the smoker that alcohol as well as caffeine often act as a smoking cue, and may trigger
strong urges to smoke after their quit date.
Alcohol
Advise the smoker that alcohol impairs judgement and reduces inhibitions so that they are at
greater risk of a lapse when drinking.
Recommend that they limit their alcohol intake in the early stages of their quit attempt and ensure
that they continue to recognise it as a high risk situation in the future.
Caffeine
Smoking increases the metabolism of caffeine so after quitting anyone who drinks tea or coffee,
and does not reduce their intake, will get higher blood caffeine levels. This can lead to clients
experiencing anxiety, restlessness and difficulty getting to sleep.
Inform clients of this and advise they reduce their consumption as appropriate.
Advise on avoiding cues
Inform the smoker that there is a close relationship between cues (or triggers) and urges to smoke,
and when faced with situations in which they used to smoke they may well experience strong urges
to smoke.
Stopping smoking requires mental energy

Resisting urges to smoke, of which there are likely to be many in the first few weeks of quitting,
requires mental energy.
Advise clients to conserve their mental energy, and to try and avoid getting tired, angry or hungry in
order that their resolve not to smoke is not weakened.
This advice will re-emphasise the amount of effort that the client is going to have to put into their
quit attempt and warn them about times at which they might be more vulnerable to lapses.
This advice also warns smokers that urges to smoke can be triggered by familiar cues and
reinforces that they will need to make small changes to their routine.
Advise smokers to avoid these situations or to minimise the time spent in them because:
'Quitting smoking is a hard enough challenge without putting yourself in situations that remind you
of smoking, avoid them if you can.'
It is best if the client can be helped to come up with their own strategies for avoiding smoking cues.
Advise on restructuring social life

Minimising the exposure to smoking cues triggered by being around family and friends who smoke
is an important component of a successful quit attempt.
It is best if the client can be encouraged to come up with their own strategies for making small
changes to their life in order to avoid smoking cues.

Summarise client choices

It is important that you summarise the choices the client has made.
To do this effectively, you should:
Listen attentively when the smoker is speaking and, when appropriate, reflect back what you think
they have said using summaries;
Confirm with the smoker their medication choice, correct usage and supply;
Summarise the reasons why the smoker wants to stop smoking, what support is available to them
and what barriers they may face;
Confirm with the client what strategies they have in place for when strong urges to smoke hit them;
Check with the smoker that your reflection accurately summarises what they were saying;
This summary of what has been discussed in this session allows the smoker to review the plans, it
also crystallises these plans in the smoker's mind.

Other interventions to deliver while summarising the session

Confirm the need for an arrangement with smoking friends, colleagues and family to reduce the
smoker's exposure to smoking and to the availability of cigarettes;
Confirm that clients have got rid of all remaining cigarettes;
Reinforce the importance of the 'not a puff' rule;
Ensure that the client knows the important role that their medication can have in reducing
withdrawal symptoms.

Practice: post quit

The post quit sessions allow you the opportunity to provide support, reassurance and advice to
your clients in order to maintain their quit attempt.
All of the post quit sessions include:
Checking on whether the client has smoked and responding appropriately;
Enquiring about medication use, side effects and supply;
Assessing withdrawal symptoms and advising on minimising them;
Asking about how difficult situations have been dealt with since the last appointment (including
urges to smoke) and what potential difficult situations are coming up;
Boosting motivation and reinforcing the 'not a puff' rule.
The final session includes these elements but also addresses longer term relapse prevention and
includes signposting to other support and materials.
The following pages and video clips demonstrate the key elements of post quit smoking cessation
behavioural support.
Progress since quit date

This video demonstrates how you can quickly and effectively get to the important issue of the
client's progress since the quit date.

Responding to clients who have smoked

It is important that you respond appropriately to clients who have smoked since their last quit date.
This video shows you how best to work with your client to re-establish the quit attempt.

Provide reward that is contingent on success

If a client has had a few slips acknowledge the effort made, but reinforce the importance of, and
rationale for, complete abstinence. Each slip sets them back; having the occasional cigarette
makes withdrawal worse, and relapse more likely.
If a client has cut down the number of cigarettes smoked per day, but not quit completely,
acknowledge that it might seem like a good idea, but explain again why it doesn't work and is not
what was agreed between you.
If the smoker is smoking daily, say that it is essential that they renew their efforts and not smoke at
all from now on.
If the client cannot re-commit to the quit attempt and the 'not a puff' rule it might be best to consider
stopping the attempt and inviting them back to the service when they want to stop smoking
completely.
Many smokers lack confidence, and they lose confidence as the quit attempt progresses, this is a
dangerous sign and you should make every effort to keep their confidence high.
It is important that you 'reward' complete abstinence and to reinforce the 'not a puff' message to
smokers who have not achieved this.
Rewarding post-quit abstinence

At every opportunity you should provide encouragement to the smoker to continue with their quit
attempt and make them feel that they can succeed this time.
Let your clients know that you have confidence in them, and expect them to come back next week
feeling proud of having succeeded in not smoking at all.
If your client has managed to remain abstinent give praise and reinforce 'not a single puff'
'Well done! Many people who relapse go back to smoking in the first few days of their quit attempt.
Managing not to smoke at all makes your chances of becoming a permanent ex-smoker much
higher'.
Provide reward that is contingent on success
If a client has had a few slips acknowledge the effort made, but reinforce the importance of, and
rationale for, complete abstinence. Each slip sets them back; having the occasional cigarette
makes withdrawal worse, and relapse more likely.
If a client has cut down the number of cigarettes smoked per day, but not quit completely,
acknowledge that it might seem like a good idea, but explain again why it doesn't work and is not
what was agreed between you.
If the smoker is smoking daily, say that it is essential that they renew their efforts and not smoke at
all from now on.
If the client cannot re-commit to the quit attempt and the 'not a puff' rule it might be best to consider
stopping the attempt and inviting them back to the service when they want to stop smoking
completely.

Many smokers lack confidence, and they lose confidence as the quit attempt progresses, this is a
dangerous sign and you should make every effort to keep their confidence high.
It is important that you 'reward' complete abstinence and to reinforce the 'not a puff' message to
smokers who have not achieved this.

Assess withdrawal symptoms

Ask your clients whether they have experienced any withdrawal symptoms since your last
appointment:
'Have you experienced any withdrawal symptoms since our last appointment and if so, how have
you dealt with them?'
The answer to this question will allow you to assess whether the smoker is using their medication
properly, and what coping strategies they are using.
An effective intervention often involves saying:
'Having a supply of medication and using it properly is important because it can help with the
withdrawal symptoms that most smokers experience when they stop. Because your body is used
to regular doses of nicotine, it has to adjust to being without it (or having much less of it if you are
using NRT). Within the first few hours of stopping smoking your body will start getting used to life
without nicotine - this adjustment results in withdrawal symptoms.'
Respond appropriately to any concerns and remind clients that these symptoms are all normal and
will pass with time as long as they do not smoke.

Ask about medication use

An important active ingredient of the support programme is optimising the client's use of
medication.
You can help your clients maximise the effectiveness of their medication by asking:
How much medication they are using;
How often they're taking it;
About any side effects they're experiencing.
The video models how this can be done.
Provide reassurance

It is important that smokers do not feel that there is anything unusual or harmful in what they are
experiencing.
This is especially true with the withdrawal symptoms and urges to smoke that they have almost
certainly experienced. You can reassure clients that these:
Are completely normal;
Will subside and disappear as long as they do not smoke;
Can be helped by proper use of medication.
Ask clients if they have any worries about their quit attempt. They will often voice concerns, and
almost always you will be able to reassure them that how they are feeling, and what they are going
through, is completely normal.
Reassure them that this is something that millions of smokers have gone through, and that with the
help of medication and the support of trained professionals they are far more likely to succeed than
those who go it alone.

Relapse prevention
There are a number of additional key competences that you can employ to help your client reduce
their risk of lapse, and relapse.
All of your interventions should aim to boost self confidence.
Explain to clients that a lapse occurs when the urge to smoke is greater than the motivation not to
smoke; and that if this is repeated it usually leads back to regular smoking - a relapse.
Encourage clients to adhere to the 'not a puff' rule, discuss any secondary goals that will help the
smoker not smoke (optimum medication use, avoiding certain situations, breaking down the week
into smaller periods of time etc.), and say:
'The best way of avoiding relapsing is to not smoke that first cigarette - if you do have a cigarette
stop right there. Commit to not smoking any more, make sure that you are using enough
medication and look at why the lapse happened.'
Stopping smoking forever can be daunting for smokers. It is therefore important to set small
achievable goals if the larger goal of quitting appears unachievable. Help the smoker to set
secondary goals that support the overall goal of not smoking in order to make the task of not
smoking at all feel more manageable.
Encourage the smoker to feel proud when a goal is achieved (such as getting through the first day,
or coffee break or their first holiday as a non-smoker) and then to focus on the next goal so as to
build upon the success of achieving the previous one.

Review ways of coping with situations where cigarettes are available, specifically when alcohol is
involved. Reinforce the importance of use of medication and, for those using oral NRT products or
the nasal spray, the role these can play at high risk times.
Strengthen ex-smoker identity
It can be useful to discuss client's transition from smoker to ex-smoker, of making the personal
change so that smoking becomes something that is not an option.
Help the smoker to construct a new identity as someone who used to smoke. This cannot be
rushed, but can be slowly introduced with phrases such as 'when you used to smoke...' and 'now
that you don't smoke...'
As part of this, you should help them to develop positive and assertive phrases to describe
themselves when they are offered a cigarette such as 'no thanks, I don't smoke any more' rather
than 'no thanks I'm trying to stop.'
Again, reinforcing the 'not a puff' rule and helping clients to develop a non-smoker identity will
protect them against relapse.
Maximise self-regulatory capacity, and skills
It is important to help the smoker identify any potential barriers to not smoking.
Following on from this it is important that you help the smoker to use techniques (mental and
physical activities) to overcome these barriers by either reducing their exposure to them or helping
them to resist the urge to smoke.
This is important because you do not want your client to be caught unawares by 'high risk'
situations, and do want them to have plans in place to help avoid and/or cope with them.
Most smokers' quit attempts fail when they meet a barrier and instead of coping with it, they lapse
and that starts the road back to smoking full time.
Having a plan to avoid or otherwise cope with the barriers is a crucial element of the behavioural
support programme.
High risk situations
High risk situations for most smokers are linked to times when their barriers are down and where
cigarettes are available and being smoked - their motivation will have to be at its strongest at these
times.
It is important to explain the importance of frame of mind:
'Your frame of mind is important: being positive about stopping smoking and knowing that there will
be hard times and periods when you feel like smoking, but that these will pass, will help.'
Invite the smoker to remind themselves about their reasons for quitting and how these can be used
during high risk situations or when strong urges strike.
High risk situations are a useful thing for people to think about between sessions. It can be useful
to ask:
'When we spoke last I suggested that you might want to think about the times you are going to
miss cigarettes the most. Have you had any thoughts about this?'
Respond appropriately and encourage clients to come up with ways of dealing with these
situations.

Discuss common methods of dealing with high risk situations and reinforce the important role that
medications can play.
Testing resolve
The standard response to anyone considering testing their resolve as a non-smoker should be:
'There is no need to test yourself as a non-smoker by being with smokers or in situations where
cigarettes are available, especially in the first few weeks of your quit attempt, until you know that
you have a good chance of passing the test.'
Facilitate barrier identification and problem solving
As well as helping the smoker to identify general barriers such as susceptibility to stress that might
make it harder not to smoke, you should help them with action planning and identification of things
that might trigger a lapse.
Once the smoker has identified any potential barriers, you can encourage them to discuss ways of
avoiding or overcoming them such as trying different ways to cope with stressful situations.
Asking 'is there any situation in which you think it is going to be more difficult not to smoke this
week?' and discussing ways of avoiding or dealing with these situations is helpful, but be careful to
allow the smoker to come up with their own solutions.
Reinforce to the smoker that stopping smoking needs to be their number one priority and that each
time they overcome an urge to smoke, they are increasing their chances of overcoming similar
ones in the future.

Respond to Carbon Monoxide reading

Remind your clients that carbon monoxide (CO) is a poisonous gas contained in cigarette smoke,
and that the test measures CO levels and verifies whether they have smoked or not.
Establish when the client last had a cigarette, measure CO ensuring that the procedure complies
with your local infection control guidelines and discuss the results with the smoker.
CO readings that confirm self-report
If the CO reading is below 10 parts per million (ppm) then you can congratulate your client on not
smoking and on achieving a 'non-smokers' reading.
Contrast this reading with the CO levels measured at the pre-quit and quit date appointments and
use this to further motivate the client to continue with their quit attempt.
Discrepancies between CO readings and self-report
If the CO monitor is reading above 10ppm, and your client is telling you they haven't smoked, you
should tell them that most smokers who report not having smoked at all in the past week have a
CO reading of 10ppm or less.
There can be some exceptions however, such as in:
Smokers who are lactose intolerant (allergic to dairy products);
Exposure to carbon monoxide from a faulty car exhaust;

Exposure to carbon monoxide from faulty gas boiler;

Using a chemical paint stripper.
Lactose intollerance can produce a gas in the breath which confuses the CO monitor. However,
most people know that they are lactose intolerant as they will experience a stomach upset after
consuming dairy products.
Encourage the smoker to return for the next appointment having not smoked to register a CO
reading of 10ppm or less.
Typically the practitioner will say:
'You have reported not smoking and I am not going to disbelieve you - after all this is your quit
attempt and there is no point in kidding yourself. So what I suggest is that you get your gas boiler/
car exhaust checked out this week to make sure you are not exposed to dangerous levels of
carbon monoxide. Then when you come back here next week having not smoked at all your CO
reading will be 10ppm or less and you can be classed as a non-smoker.'
This is important because you need to ensure that the smoker is not exposed to dangerous levels
of carbon monoxide.
Low CO readings in smokers
It is possible that a smoker who doesn't smoke many cigarettes and hasn't smoked for a number of
hours may have a low - less than 10ppm - CO reading.
This can happen with morning appointments, when the smoker hasn't smoked that day yet. In such
cases it is worth stating that CO accumulates in the body during the day, and were the test to be
repeated towards the end of the day there is little doubt that it would be higher.
Carbon monoxide poisoning
A smoker may exhibit abnormally high expired CO levels (above 100ppm). In such cases, they
should be given advice about possible acute CO poisoning, and advised to attend their local
Accident and Emergency department.

Prompt review of goals

Reviewing set goals that support the overall goal of not smoking is important if they are to
contribute towards the task of not smoking at all.
Help the smoker evaluate how they have got on in relation to their secondary goals such as:
Optimum medication use;
Avoiding certain situations;
Breaking down the week into smaller periods of time;
and discuss with the smoker how these goals have contributed towards their overall goal of not
smoking.

The last session: signpost further support

Direct towards appropriate support

Inform clients that having managed not to smoke for four weeks gives them a really good chance
of never smoking again.
Remind them that they are not out of the woods yet however, and that continued medication use is
very important.
Let clients know that they can always contact you for some additional support if they are going
through a tricky time or have any questions about maintaining their abstinence.
You can also let clients know that, should they unfortunately return to smoking at some point in the
future, they can always come back to the service.
Give the smoker the names of trusted websites that will support their quit attempt such as:
NHS Smokefree;
QUIT;
No smoking day.
Also give the telephone helplines that can support a quit attempt:
NHS Free Smoking Helpline: 0800 022 4 332 (7 days a week, 7 am to 11 pm);
NHS Pregnancy Smoking Helpline: 0800 169 9 169 (Mon to Fri, 11 am to 6 pm);
QUIT line 0800 00 22 00 (7 days a week, 9 am to 9 pm).
There are also 5 NHS Asian tobacco helplines:
Urdu - 0800 169 0 881 (Tuesdays, 1 pm to 9 pm);
Punjabi - 0800 169 0 882 (Tuesdays, 1 pm to 9 pm);
Hindi - 0800 169 0 883 (Tuesdays, 1 pm to 9 pm);
Gujarati - 0800 169 0 884 (Tuesdays, 1 pm to 9 pm); and
Bengali - 0800 169 0 885 (Tuesdays, 1 pm to 9 pm).
Direct towards appropriate support materials
Provide the smoker with local and national written materials that support the information that you
have provided throughout the behavioural support programme.
It is important that clients can access information that will support their continued abstinence and
possibly help prevent relapse.
Practice: groups

Behavioural support in closed groups has been proven to have a powerful effect and produces
better quit rates than seeing smokers individually.
Only a minority of stop smoking services offer closed groups and, because of this, attending
training courses specialising in group treatment is probably recommended for practitioners to gain
the expertise and experience of treating smokers in groups.
However, this section of the course covers the key elements known to contribute to the best quit
rates for participants of groups of smokers who want to quit.
Screening group participants
In order to screen smokers for suitability for attending groups, and to enable you to manage for
physical and psychological comorbidity, you will need to use a questionnaire to collect information
from clients. This should include readiness and willingness to quit.
The questionnaire can be sent to smokers prior to the first group or completed by clients as they
arrive.
You should review the information given with each individual smoker to clarify any discrepancies,
ask whether they have any physical or psychological problems that may affect their quit attempt,
and further assess relevant health issues.
The questionnaire and conversation will allow you to identify issues which may make smokers
unsuitable for group support, such as inability to abstain from alcohol on group days or severe
mental health problems. It will also allow you to assess their ability to commit to group support and
to attend each group session.
Respond appropriately, including transferring the smoker to an individual behavioural support
programme if necessary.
Using a questionnaire in this way ensures that important assessments can take place without
personal details being revealed to other group members.
In order for group motivational processes to be most effective, each participant needs to be able to
commit to the programme and to offer support to others, as well as sharing their own concerns and
experiences.
Screening is necessary because groups are sensitive to negative influences such as poorly
motivated individuals, high drop-out rates and disruptive group members.
Identifying issues early, and screening out unsuitable individuals, enables you to prevent problems
arising later within the group when the experience of the individual smoker, or of others, may be
compromised.
Structure of the group sessions
It is recommended that you work with at least one other stop smoking practitioner when running
closed groups. It is important that both of you are clear about the format of each session, so that
facilitation is consistent.
Planning the structure of the group support sessions will ensure that important information is
provided, but that enough time is allocated for the group to build trust, share experiences and learn
from each other.
Session 1

Allocate the first session to information giving and answering questions, making explicit the
commitment involved in attending group support, and ensuring smokers know what they can
expect in terms of abrupt cessation, withdrawal symptoms, behavioural support, medication and
carbon monoxide measurements. Facilitate medication supply.
Session 2
This is the quit date. Confirm medication choice and ensure proper use (in the past week with
varenicline; in the session right now with NRT). Discuss dealing with urges to smoke and high risk
situations and encourage group members to provide suggestions. Emphasise the 'not a puff' rule
and get group members to commit to the rule and to each other.
Session 3 onwards
This, and subsequent sessions, focus on developing an identity as a non-smoker and the
facilitators take a less prominent role, encouraging group interaction, problem solving and
discussion. Medication use and supply will be covered, along with dealing with urges and high risk
situations. Re-emphasise the 'not a puff' rule and get group members to commit to the rule, and to
each other, at the end of each group session.

Facilitate medication choice in a group setting

Group settings allow participants to be actively involved in the education process that precedes
medication choice.
Describe the range of stop smoking medications available to the group, and encourage discussion
from the group members. If you support and encourage the reporting of prior experiences with
medication from group members it will enable participants to make their medication decision based
on:
Accurate information;
Realistic expectations;
The experience of other group members.
Of course, you will have to explain that contraindications, cautions, or personal preferences will
mean that different people will use different medications.
You will also need to emphasise that stop smoking medications are only part, admittedly an
important part, of a quit attempt and that the different experiences reported after the quit date by
group members is not a reason for changing individual's medication choice.
Whichever medication people use, optimal medication use is the key to maximising the chances of
stopping smoking permanently.

Summary

In this video Robert West summarises the main components of effective behavioural support, and
the course.
When you have watched it, provided you feel familiar with the course content, click next to go
straight to the practitioner assessment.