Heart and lungs

NICE publishes guidance on cutting down smoking

"Smokers urged to 'cut down' rather than quit," The Daily Telegraph reports. The story comes from landmark national guidance on how healthcare professionals should help smokers who find it difficult to give up. The guidance, produced by the National Institute for Health and Care Excellence (NICE), is the first in the world to say that nicotine replacement therapy such as patches and nasal sprays can be used to help hardened smokers reduce the amount they smoke.

Quitting smoking altogether is the healthiest thing you can do if you smoke, but this new guidance addresses the fact that many smokers may not be ready or able to quit in one go, while others want to stop smoking without giving up nicotine. For these people, NICE recommends a pragmatic "harm reduction" approach that includes the use of nicotine replacement therapy.

Professor Mike Kelly, director of the NICE Public Health Centre, said: "Over 79,000 deaths in England each year are due to smoking tobacco. Put simply, people smoke for the nicotine, but die because of the tar in tobacco. However, nicotine inhaled from smoking tobacco is highly addictive, which is why people find it so difficult to stop smoking.

"If you are a smoker, quitting smoking is the best way to improve health, and stopping in one step is most likely to be successful. This guidance recommends harm reduction as an additional new option, particularly for those who are highly dependent on smoking who want to quit but can't just stop in one go."

Why is NICE producing this guidance?

NICE points out that although the best way to reduce the harm from smoking is to stop completely, many people are unable to do this in one step. For example, only 4% who try to give up without help are successful for a year or longer, and only 15% of those who quit using the NHS Stop Smoking Service.

NICE says that although existing evidence is not clear about the health benefits of reducing smoking, people who cut down on how much they smoke are more likely to stop smoking eventually, particularly if they are using licensed nicotine-containing products.

The guidance recommends a "harm reduction" approach, with or without the temporary or long-term use of licensed nicotine-containing products.

The options it addresses are:

  • stopping smoking, but using licensed nicotine-containing products as long as necessary to prevent relapse
  • cutting down before stopping smoking (cutting down to quit)
  • smoking reduction
  • temporary abstinence from smoking, such as stopping smoking during your working day

NICE says the advice is particularly relevant to people who are highly dependent on nicotine and groups of people whose smoking prevalence is higher than average. It says this includes people with mental illness, those from lower socioeconomic groups, and lesbian, gay, bisexual and transgender people.

It also says evidence shows that reductions in smoking without the support of a nicotine replacement product are unlikely to yield any health benefits. This is due to what is known as compensatory smoking, where you "make up" for missed cigarettes by smoking more at home or inhaling more deeply.

What are NICE's main recommendations on smoking?

NICE's guidance is mainly aimed at healthcare professionals and organisations. For this reason, its recommendations relate to what these professionals and organisations should do to help people who smoke quit or cut down.

Raising awareness of licensed nicotine replacement therapy

NICE wants organisations responsible for tackling tobacco use, such as local authorities, to promote licensed nicotine-containing products as safer to use than tobacco. They should also provide information on how to get them.

Self-help materials

Stop smoking services, manufacturers of nicotine-containing products and retailers should provide self-help advice on how to cut down gradually, as well as provide information about the benefits of doing so using nicotine-containing products for people who smoke a lot.

Choosing a 'harm reduction' approach

Anyone involved in stop smoking programmes and support should explain harm reduction for anyone who does not want, or is not ready, to stop smoking completely. Nicotine-containing products make it easier to cut down, increase the chances of stopping in the long term, and should be recommended or supplied.

Behavioural support

Stop smoking services should help smokers set goals on cutting down, such as increasing intervals between cigarettes and delaying the first cigarette of the day.

Advising on licensed nicotine-containing products

Stop smoking services should reassure people that nicotine-containing products are a safe and effective way of reducing the amount they smoke. They can be used as a complete or partial substitute for tobacco in the short or long term, and NICE advises that it is better to use these products and reduce the amount people smoke than allow them to continue smoking at their current levels.

Services should also explain how to use these products correctly and in a sufficiently high dose to control cravings. For example, people should replace each cigarette with a nicotine-containing product, such as a lozenge or gum – ideally before the usual time they would have had the cigarette – to allow for slower nicotine release.

NICE points out that some nicotine-containing products are not licensed (for example, electronic cigarettes and topical gels) and, "their effectiveness, safety and quality cannot be assured", but also says they are likely to be less harmful than cigarettes.

Supplying nicotine-containing products

Stop smoking services, GPs and other healthcare professionals, prison health service staff, custody officers and police medical examiners should offer all types of nicotine-containing products to people who smoke as part of a harm reduction strategy, either singly or in combination.

These products can also be used to help prevent a relapse in people who have stopped or reduced the amount they smoke. For example, patches could be offered with gum or lozenges. Smokers should be advised that using more than one product is more likely to be successful, particularly with heavier smokers.

Supporting temporary abstinence

Stop smoking services should offer advice and support to people who want to abstain from smoking temporarily.


If you are worried about your smoking – and you should be worried if you smoke – your GP will be able to advise you on the best ways to quit or cut down. GPs provide a useful first point of contact for a range of stop smoking services that should be able to help you cut down and eventually quit.

Don't be discouraged if you have tried to quit before and failed. Like a driving test, many people don't make it first time around, but most will get there in the end.

Finally, don't make it needlessly hard for yourself. Going "cold turkey" (trying to quit without the help of nicotine replacement therapy) has a very low success rate. You are much more likely to cut down or quit for good if you use a nicotine replacement therapy product, such as gum, patches, lozenges or a spray.

Read more about established, evidence-based methods you can use to break the habit.

NHS Attribution