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Smoking cessation

Module summary

This key-questions module will examine the current approaches to smoking cessation, including who should be involved, the help and support available to healthcare professionals and their patients, and the treatments landscape.

Learning outcomes

After completing this module, you should be able to:

  • Recognise why all healthcare professionals should get involved in preventing and treating tobacco dependency
  • Access a wealth of resources to help and support you and your patients
  • Appreciate how a carbon monoxide monitor can be useful in a quit attempt
  • Outline the wide range of treatments available to smokers alongside the NHS behavioural support services and help a patient choose the right one for them
  • Identify the main withdrawal symptoms from smoking, and discuss some of the ways to help patients cope with them, including in a smoke-free hospital setting
  • Discuss harm-reduction approaches, including the role of e-cigarettes

Introduction

Smoking remains the leading cause of preventable illness and death in England, accounting for about 96,000 deaths a year in the United Kingdom. As well as reducing quality of life and life expectancy, it harms nearly every organ in the body: among other diseases, it causes lung cancer, respiratory disease, heart disease, and cancers of the lip, mouth, throat, bladder, kidney, stomach, liver and cervix. For every death caused by smoking, approximately 20 smokers are suffering from a smoking-related disease. The cost of smoking to the NHS in England is estimated to be £2 billion per year.1 Helping patients quit smoking is the highest-value intervention for today’s NHS and Public Health system.2

Author details 

This module was created by Darush Attar-Zadeh, the Respiratory Lead Pharmacist for Barnett CCG.

Many people (including some healthcare professionals) believe that smoking is a lifestyle choice, or is a problem for the local stop smoking services or pharmacies to solve.

Tobacco dependency is a long-term condition that starts in childhood. An example of the effects of this was highlighted by the 2014 National Review of Asthma Deaths. It reported that 65% of the deaths due to asthma had ‘preventable risk factors related to the patient or family and their environment’ – the risk factor in one third being regular exposure to tobacco smoke. Shockingly, this included child smokers, with one patient as young as ten.3

The smokers who need us most are in our hospitals, they are consulting their HCPs in the community, they are in lower socio-economic areas, they are using our mental health services, they are in our prisons, they are giving birth to low birthweight babies.

GPs, nurses and pharmacists are trusted healthcare professionals and need to treat many of the sick smokers we are seeing with long-term conditions. There is evidence that the advice of the GP is still one of the most influential factors for patients who need to stop smoking.

In some areas in the UK, stop smoking services are being decommissioned. We need to remember that helping patients quit smoking is the highest-value intervention for today’s NHS and Public Health system, saving and increasing healthy lives at an affordable cost.2

Offering ‘Very Brief Advice’ is a skill that is easily taught. It is not just a chat with a smoker but requires a skilled conversation. Simple advice from a healthcare professional can have a small but significant effect on smoking cessation – more so than nicotine replacement therapy alone.3 Advice or counselling given by GPs significantly increases the likelihood of successfully quitting. However, it is unlikely to be possible to spend 10 minutes in a single consultation discussing smoking when this may not have been the primary focus of the consultation, so offering ‘Very Brief Advice’ (VBA; see Figure 1) to smokers at every opportunity is essential.

VBA is designed to be delivered in around 30 seconds and uses the Department of Health-recommended ‘AAA’ approach: Ask, Advise, Act.

Ask patients if they smoke and if they have thought about stopping. You could do this when patients are identified as smokers from your records. If the records show an ex-smoker – Ask patients ‘how’s the stopping smoking going?’ Smoking is unfortunately described as a ‘chronic relapsing condition’ and needs proper treatment (support + medication – by properly trained individuals).

Advise patients that stopping smoking is the single most important thing they can do to improve their health and that of others around them.

Act on the patient’s response by building confidence, giving information or referring to an NHS stop smoking service (this could be your own or another local service).

figure-1-smoking-cessation
Figure 1. Summary of very brief advice on smoking

Every health worker coming into contact with a patient who smokes can ensure they know how to provide a brief intervention.

Learn how to provide this high value intervention at:

NCST e-learning

BMJ Learning

The very brief advice (VBA) training takes only 20 minutes and the intervention can take as little as 30 seconds to complete in a real consultation.

The Royal College of Physicians/Royal College of Psychiatrists 2013 joint recommendations include:5

  • All professionals working with or caring for people with mental disorders should be trained in awareness of smoking as a major health issue, to deliver brief cessation advice, to provide or arrange further support for those who want help to quit and to provide positive (i.e. non-smoking) role models. Such training should be mandatory.

Find your local stop smoking service:

Go to the NHS Smokefree site www.nhs.uk/smokefree and look for the nearest stop smoking service to you. Also note there are other useful contacts and apps you can download so you know what support is available to the smoker. The Smokefree resource website provides lots of useful information for those delivering NHS stop smoking services, including policy updates. If you are not currently providing NHS stop smoking services, you can use the site to find out details of your nearest service so that you can refer patients. You can also order leaflets, posters and campaign information from Public Health England, here.

This desktop test measures exhaled carbon monoxide (CO) levels, which are raised in smokers. You can make it a routine part of the appointment: simply ask ‘Would you like to know your level?’

This can be done following the Ask, Advise and Act approach to help patients who smoke and it can potentially make the difference to whether or not a patient makes a quit attempt.

The CO monitor has proven benefit in specialist quit smoking settings as a motivational change tool. More HCPs are becoming trained to support people to make a quit attempt through very brief advice and by having the right conversations, meaning that there is an opportunity to utilise the CO monitor in everyday clinical settings too. The finding of a raised reading emphasises the measurable harm of smoking. Any subsequent reduction following treatment and behaviour change provides motivation, reward and immediate feedback on health gains. As part of the treatment protocol, praise can then be provided – a reinforcement of staying smoke-free. Encouraging the ex-smoker to not have even a ‘single puff of a cigarette’ and to continue attending the weekly support sessions is crucial. The patient is four times more likely to stop with NHS support and treatment.4

The following this YouTube link demonstrates how to use one of the currently available CO devices.

The London Clinical Senate ‘Helping Smokers Quit’ Delivery team have also produced some great documents to support you in interpreting the results, and provide information on where to source the machines and the costs, accessible here.

Evidence shows that medication alone isn’t very effective at helping a person stop smoking and stay stopped. Evidence-based behavioural support has shown to significantly enhance the effects of the medication (see Figure 2).

figure-2-smoking-cessation

Figure 2. Effectiveness of different types of smoking cessation support6

Smoking is an integral part of many smokers’ lives, particularly long-term smokers. To a person who smokes, quitting means much more than just overcoming the pharmacological effects of nicotine; it effectively means changing their lives – sometimes even changing their friends or their behaviour with their friends or work colleagues. It may involve changing their regular routines to bypass situations where they might usually light up, e.g. when driving in the car.

If we take the above factors into consideration, it will help us understand that there is no ‘one size fits all’ in the treatment of smoking cessation. We therefore need to tailor our stop smoking support programmes to each smoker and try out proven strategies that may work for the client we are helping.

To do this we need to first understand what’s going on in the smoker’s world by asking some simple but vitally important questions, for example:

  • Have you tried stopping smoking before?
  • What’s the longest period you’ve managed to stop for? (Even if it is for a short period, e.g. 2 days, congratulate the person for their efforts: That’s amazing! How did you manage to do that?)
  • Out of the 20 cigarettes you smoke, which ones are the most important to you?
  • What sort of things do you think you can do to prepare yourself for quit day?

There are many more questions we need to explore during a stop smoking session; however, this provides a little taster. The next question also explores what trained stop smoking advisors look at when assessing how dependent a smoker is on nicotine.

There’s never been a better time to quit smoking with so many treatment options being available on the market. The licenced medications nicotine replacement therapy (NRT), varenicline (Champix®) and bupropion (Zyban®) have all been shown to increase a person’s chances of stopping by four times when used in combination with NHS intensive support.4

Before going through the treatments it’s important to identify a person’s level of nicotine dependence, and this can be done by using a simple nicotine dependency test (Figure 3).7

figure-3-smoking-cessation
Figure 3. Nicotine dependency test7

Figure 2 shows the effectiveness of smoking cessation treatments. It shows that varenicline plus behavioural support is the most effective of the licenced treatments.

With tobacco dependency, as with other chronic conditions, it’s important that the patient is involved in the decision-making process and that all treatment options are discussed so the patient can find the right treatment that best suits them.

Varenicline (Champix®) is available in two doses: a 0.5 mg (white) tablet and a 1.0 mg (blue) tablet.7 It alleviates symptoms of craving and withdrawal (agonistic activity – stimulating the effects of nicotine at receptor sites). It also reduces the rewarding and reinforcing effects of nicotine (antagonistic activity – reducing the effects of nicotine at receptor sites).

Put simply, many patients find that Champix® can reduce the pleasurable effects of smoking with the blocking action, while at the same time it can take the edge off cravings by releasing some dopamine.

A typical titration pack (2 weeks) includes 11 x 0.5mg tablets and 14 x 1 mg tablets. Further supplies after the starter pack should be 28 x 1mg tablets (2 weeks).

Common side effects (experienced by approximately 1 in 10 patients) include:

  • Nausea (approximately 1 in 3)
  • Headaches
  • Insomnia/abnormal dreams.

These side effects may resolve over time; if not, reduce the dose if required.

Varenicline should be used as follows:

  • Set a quit date with client. Start tablet use 1–2 weeks before this date
  • Treatment should last for 12 weeks (extend for a further 12 weeks or taper dose if required)
  • Clients should be advised to swallow the tablets whole with water, with or without food (better with food)
  • Dose: 1mg twice daily following a 1-week titration

Contraindications include allergy to varenicline or excipients, people under 18 years of age and those who are pregnant or breastfeeding.

Special precautions include:8

  • Moderate or severe renal impairment (reduce dose to 1 mg once daily for severe impairment)
  • Epilepsy
  • Psychiatric illness

There are several research papers demonstrating the safety of varenicline in patients with stable mental health conditions. A good starting point would be to visit the National Centre for Smoking Cessation and Training (NCSCT) varenicline briefing, which covers safety in patients with stable cardiovascular disease and reassurance in mental health patients, or the London clinical senate varenicline briefing.9,10

The Lancet also published a paper in April 2016 highlighting further safety data, summarised here.11

(EAGLES) Neuropsychiatric safety and efficacy of varenicline, bupropion and nicotine patch in smokers with and without psychiatric disorders. A Double-blind, randomised, placebo-controlled trial. Published April 2016, The Lancet.11

  • Conducted at the request of, and designed in conjunction with, the FDA and EMA
  • 24 weeks, 4 treatment arms; all active treatments blinded in a triple-dummy design
  • 12 weeks’ active treatment and 12 weeks’ follow-up
  • N=8000, including 2000 on each arm, 1000 with and 1000 without a psychiatric disorder
  • Patients aged 18-75 years; ≥10 cigarettes/day and CO>10 ppm at screening

Conclusion:

  • The study did not show a significant increase in neuropsychiatric adverse events attributable to varenicline or bupropion relative to nicotine patch or placebo. Varenicline was more effective than placebo, nicotine patch and bupropion in helping smokers achieve abstinence, whereas bupropion and nicotine patch were more effective than placebo.

You can find the latest SPC of varenicline here: www.medicines.org.uk/emc/

Update April 2016: ‘As a measure of its safety in patients, varenicline is no longer a ‘black triangle’ medication’. The black triangle symbol ▼, which is used on medicines to indicate that additional safety monitoring is required for a medicine in the UK, has been removed from varenicline (Champix®) by the EMA.12

The Summary of Product Characteristics (SPC) states that patients should be advised to discontinue treatment and seek prompt medical advice if they develop agitation, depressed mood of concern, or suicidal thoughts.8

All adverse and suspected adverse reactions should be reported using the ‘Yellow Card’ reporting system.8

Currently there are 8 different forms of NRT on the markets and some of the products, e.g. gum, lozenge and patch, come in different strengths.

To help us better understand the treatments that are available, Figure 4 below highlights how products can vary in blood concentrations and speed of action in the first hour. Some of the features listed below may help you and the patient when deciding on what the most appropriate NRT product is for an individual. The NCSCT has an online medication module (accessible here) that goes through each of the products in more detail.

  • Speed of Action: on a scale of 1 to 5 (where 1 is low and 5 is high), how important is it for the patient that the product can control cravings quickly? If 4 or 5, consider a fast acting product such as an oromucosal spray (mouth spray), nasal spray or oral strip (a film that dissolves on the roof of the mouth) as these are the only licensed products on the market to reach high concentrations within the first 10 minutes.
  • Strength and Dose: if the nicotine dependency test (see question 6) indicates that the patient’s nicotine dependency is high, then consider recommending the highest strength NRT products in combination from the very first day of the quit attempt e.g. high strength patch with high strength short-acting product. It’s important to not be too concerned with overdosing (see figure 5). HCPs should be more concerned with underdosing in medications as the patient will inevitably experience worsening withdrawal symptoms.

For example a patient can use up to 15 pieces of 4mg gum or lozenge a day, 6 inhalator cartridges, 15 oral strips, 40 microtabs, 64 sprays of the mouth or nasal spray.

The up-to-date SPCs for each product can be found here www.medicines.org.uk/emc/

During the structured stop smoking sessions with the specialist advisor, coping strategies will also be explored to help distract the patient from potential cravings.

  • Importance of a hand-to-mouth device (i.e. appearing like a cigarette): on a scale of 1 to 5 (where 1 is low and 5 is high), how important is it for you to have a product that looks like a cigarette? If 4 or 5, consider an inhalator in combination with a patch.
  • Technique: the stop smoking advisor should offer accurate advice on the NRT products and coach the patient on proper usage (see NCSCT e-learning module for more details). Unfortunately, poor technique is one of the main reasons why patients terminate their treatment.

For example:

  • some people discontinue use of a nicotine patch immediately if they get any form of skin irritation or redness – yet this is normal and is one of the common side effects
  • it’s important patients are shown how to break the seal and open the child-resistant container of a mouth spray as they need to dispense a fine mist rather than a jet
  • some users chew nicotine gum like regular gum which means nicotine isn’t absorbed via the buccal route (between the gum and cheek)
  • many patients draw on an inhalator like a regular cigarette, however, absorption takes place orally and not via the lungs so short shallow puffs are recommended

After explaining and demonstrating technique, ask the patient ‘Which product appeals to you most?’

  • Length of course: it’s important that patients stay on their treatment for a minimum of 8 weeks to get the best possible outcome. This will need to be explained to them. You can ask the patient ‘On a scale of 1 to 5 how important do think it is to stay on your treatment for a minimum of 8 weeks?’ If they say 4 or 5 acknowledge that’s right and it will greatly improve their chances of stopping and staying stopped. If less than 4 then highlight that this is one of the biggest reasons why people go back to smoking as the cravings can hit them when they least expect it. A common analogy that is used is that it’s important to stay on the course and complete it, just as they would for a course of antibiotics. They are more likely to stay stopped and experience fewer withdrawal symptoms if they complete the course.
  • Top Tip: for all medication discuss:
  • Technique
  • Strength and dosage
  • Treatment duration
  • Problems with irregular use

figure-4-smoking-cessation

Figure 4. Nicotine levels in blood plasma13

  • Voke and e-Voke: currently there are two NRT products that look like electronic cigarettes that have MHRA approval and could be launched in 2017. We have to manage expectations on these products and would still need to signpost patients to the NHS stop smoking services or specialist in-house advisors for the support. The licenced e-cigarette-looking devices may offer a different experience to the user (smoker) compared to the inhalator, as it mimics the cigarette more closely. See product details on Voke (here) and e-Voke (here).
  • Cytisine (Tabex): Cytisine is not licenced in the UK.
    • Cytisine is an agonist of nicotinic receptors
    • Varenicline is derived from cytisine
    • Cytisine has been used to treat tobacco dependence for 40 years in Eastern Europe
    • Cytisine is sold as a smoking cessation drug by a Bulgarian firm under the commercial name of Tabex
  • Nortriptyline: Nortriptyline is not licenced in the UK. It is a tricyclic antidepressant that has been shown to be as effective as bupropion and NRT in aiding smoking cessation. However, adverse effects associated with nortriptyline may not be well tolerated in some patients, e.g. anticholinergic effects (dry mouth, blurred vision) and sedation/drowsiness.

It’s important that all licenced options are available on the hospital formulary.

‘Licensed pharmacotherapy for smoking cessation should be readily available at all times of day in the hospital wards and pharmacy. NRT (all modalities) and varenicline (Champix®) should be available on hospital formulary and easily accessible from ward and/or pharmacy stocks. Patients in hospital who are current smokers should be offered and encouraged to accept NRT or varenicline (with support from the Hospital Smoking Cessation Practitioner (HSCP)) to alleviate withdrawal while in a smoke-free hospital.’

‘Hospitals should routinely offer a full range of nicotine replacement therapies (NRT), varenicline (Champix®) and bupropion (Zyban®). The counsellor and/or consultant with responsibility for the service should agree with the hospital pharmacy an efficient way of providing this pharmacotherapy to both outpatients, inpatients and staff who smoke and wish to quit.’

Many hospitals across the UK don’t have all treatment options available to patients including some forms of NRT, buproprion or varenicline. The London Clinical Senate has produced some guidance (accessible here) for clinicians on ‘how and why to prescribe varenicline in hospital settings’ as there is very little or no use in some hospitals across London.

Lots of people start smoking again because they feel they can’t cope with the withdrawal symptoms. The first few days are hard, but the symptoms are a sign that the body is starting to recover. Table 1 lists the most common symptoms, what’s happening in the body, and how to cope.

poop
Table 1. Symptoms of nicotine withdrawal, and ways to cope

Scientists have found 5300 chemicals in a cigarette so far. All patients should be made aware that when they go smoke-free they’ll be going from potentially 5300 chemicals down to 1 (e.g. if using varenicline or NRT and support to help them).14 Having access to a ‘tar jar’ (Figure 5) will support a GP or colleague in a consultation to remind the smoker of the worst chemical in a cigarette or roll-up etc.

Tar contains benzopyrene, a by-product of combustion (burning) of organic material which is found even in herbal cigarettes, low-tar cigarettes, cannabis smoking and shisha.

figure-6-smoking-cessation

Figure 5. A ‘tar jar’

Guidance from the National Institute for Health and Care Excellence has recommended a harm reduction approach to dealing with tobacco.15

The aim of the guidance is to primarily help people who may not be able (or want) to stop abruptly, may want to stop smoking without necessarily giving up nicotine, or may not be ready to stop completely but may want to reduce the amount they smoke. While quitting smoking remains the primary message this alternative method will allow smokers to reduce harm to themselves using a different approach.

In the guidance, nicotine replacement therapies are advocated as a less harmful alternative to smoking tobacco and should be recommended to smokers who are unable or unwilling to quit completely in order to help them cut down.

Nicotine replacement therapies, varenicline, buproprion and electronic cigarettes (presently unlicensed) are all considered a safer alternative to smoking as they contain only nicotine and not tar, which is the primary source of harm from tobacco.

The possibility of some harm from long-term e-cigarette use cannot be dismissed due to inhalation of the ingredients other than nicotine, but the risk is likely to be very small, and substantially smaller than that arising from tobacco smoking. With appropriate product standards to minimise exposure to the other ingredients, it should be possible to reduce risks of physical health still further. Although it is not possible to estimate the long-term health risks associated with e-cigarettes precisely, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower.16

Potentially e-cigarettes could be the ideal NRT, as they:

  • Can raise the blood level of nicotine quickly (by at least 10 ng/ml in 10 minutes)
  • Have a formulation that minimises local side effects and does not include the main carcinogenic chemicals found in tobacco
  • Incorporate sensory properties and behavioural rituals of the kind that help to make cigarette smoking so attractive
  • Allow users to regulate their nicotine blood concentration

The NCSCT releases and updates the e-cigarettes briefing.17 Currently it’s a 43-page document with lots of facts, figures and information on topics and questions such as:

  • What are 1st, 2nd, 3rd generation e-cigarettes?
  • Which e-cigarettes shall I start with?
  • Technique
  • Success rates with NHS behavioural support
  • How much do they cost?
  • Recommendations in practice
  • Regulation
  • Can they explode?

Once you’ve identified where your local stop smoking service is, it will then hopefully ensure you receive a consistent, high quality service.  It will also provide you with local training that should follow a national competency framework.18 The NCSCT has evidence for the effectiveness of a range of behavioural change techniques (BCTs). These BCTs have been incorporated into an NCSCT Standard Treatment Programme that consists of six sessions: pre-quit, quit date and four post-quit sessions. The Standard Treatment Programme also acts as a guide to help practitioners structure the content of weekly, individual face-to-face interactions with smokers and gives examples of questions and phrases to use when undertaking interventions. You can learn more about the Standard Treatment Programme in this NCSCT document.

The NCSCT has links to additional specialist modules that have assessments at the end:19

  • Medication module
  • Mental health and smoking cessation
  • Pregnancy and smoking cessation
  • Very brief advice
  • Very brief advice on second-hand smoking
  • Very brief advice on smoking for pregnant women
  1. Action on Smoking and Health, 2016. Smoking Statistics: Illness and Death. Available at: ash.org.uk/files/documents/ASH_107.pdf. Last accessed: November 2016.
  2. NHS London Clinical Senate, 2016. Helping smokers quit. Available at: www.londonsenate.nhs.uk/wp-content/uploads/2015/04/Helping-Smokers-Quit-Report-July-2016.pdf. Last accessed: November 2016.
  3. Royal College of Physicians, 2014. Why asthma still kills. National Review of Asthma Deaths. Available at: www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills. Last accessed: November 2016.
  4. NHS Stop Smoking Service, 2011. Local stop smoking services: service delivery and monitoring guidance 2011/12. Available at: www.ncsct.co.uk/usr/pub/delivery-and-monitoringguidance-2011-and-2012.pdf. Last accessed: November 2016.
  5. Royal College of Physicians and Royal College of Psychiatrists, 2013. Smoking and mental health. Available at: cdn.shopify.com/s/files/1/0924/4392/files/smoking_and_mental_health_-_key_recommendations.pdf?7537870595093585378. Last accessed: November 2016.
  6. West R, Owen L. Estimates of 52-week continuous abstinence rates following selected smoking cessation interventions in England. Available at: www.smokinginengland.info Version 2.
  7. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for nicotine dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86:1119-27.
  8. Summary of product characteristics. Pfizer Ltd, 2016. Available at: www.medicines.org.uk/emc/medicine/19045. Last accessed: November 2016.
  9. National Centre for Smoking Cessation and Training, 2016. Varenicline: effectiveness and safety. Available at: www.ncsct.co.uk/usr/pub/Varenicline_effectiveness_safety.pdf. Last accessed: November 2016.
  10. NHS London Clinical Senate, 2016. Why and how to prescribe varenicline in hospital. Available at: www.londonsenate.nhs.uk/wp-content/uploads/2015/04/Why-and-how-to-prescribe-varenicline-in-hospital.pdf. Last accessed: November 2016.
  11. Anthenelli RM, Benowitz NL, West R et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet 2016;387:2507-20.
  12. European Medicines Agency. Champix: procedural steps taken and scientific information after the authorisation. Available here. Last accessed: November 2016.
  13. Royal College of Physicians, 2000. Nicotine addiction in Britain.
  14. Cancer Research UK. Smoking facts and evidence. Available at: www.cancerresearchuk.org/about-cancer/causes-of-cancer/smoking-and-cancer/smoking-facts-and-evidence. Last accessed: November 2016.
  15. National Institute for Health and Clinical Excellence. Public health guidance PH45. Tobacco: harm reduction approaches to smoking. 2013. Available at www.guidance.nice.org.uk/ph45. Last accessed: November 2016.
  16. Royal College of Physicians, 2016. Nicotine without smoke: tobacco harm reduction. Available at: www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0. Last accessed: November 2016.
  17. National Centre for Smoking Cessation and Training, 2016. Electronic cigarettes: A briefing for stop smoking services. Available at: www.ncsct.co.uk/publication_electronic_cigarette_briefing.php. Last accessed: November 2016.
  18. National Centre for Smoking Cessation and Training, 2016. NCSCT Training Standard. Available at: www.ncsct.co.uk/publication_ncsct-training-standard-learning-outcomes-for-training-stop-smoking-practitioners.php. Last accessed: November 2016.
  19. National Centre for Smoking Cessation and Training, 2016. Training. Available at: www.ncsct.co.uk/pub_training.php. Last accessed: November 2016.

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