Clinical FeaturesRespiratory

Smoking cessation: An Essential but Under-Utilised Pillar of Irish Healthcare

Abstract: Smoking remains the single leading cause of preventable disease, disability and death worldwide. Currently 18% of Irish adults are active smokers, and recent years have seen an upward trend of young people developing a nicotine addiction, in part due to the rise in popularity of electronic nicotine delivery systems (ENDS). Smoking cessation services are an essential component of tobacco control, and play a key role in meeting the goal of a Tobacco-Free Ireland.

In this paper we will analyse current prevalence and trends in smoking habits in Ireland, and discuss the impact of ENDS in the market, particularly the impact on Irish teenagers and potential legislation to tackle this novel challenge. We aim to identify successful smoking cessation frameworks worldwide and discuss the benefits to both the patient and the health system. A local audit conducted in Galway University Hospital provides insight into current smoking cessation practise and we have identified potential methods to improve local systems. We will review the National Stop Smoking Guideline 2022, in particular it’s application to the hospital setting and discuss the need for increased training among all healthcare staff in smoking cessation provision.

Meeting the goal of being tobacco-free by 2025 is dependent on accelerating progress with smoking cessation in Ireland, and this paper aims to identify current challenges to Irish smoking habits and identify an effective approach to improving our smoking cessation services.


Tobacco use is the leading cause of preventable death, disease and disability worldwide.1 The World Health Organisation (WHO) describes current tobacco usage worldwide as a global epidemic.

The Healthy Ireland Report 2022 (HI) reports that 18% of the population of Ireland are current smokers. There has been a significant shift in demographics in Ireland with the Central Statistics Office publishing data for the year ending 2022, showing the largest 12-month increase in the population of Ireland since 2008, in part accounted for by a 15-year high in immigrant arrivals.2 These demographic shifts will have a major impact on smoking prevalence; for example the rapid increase in Ukrainian nationals to Ireland will ultimately result in an increase in overall smoking numbers; it was estimated that in 2022, 27.4% of the Ukrainian adult population smoked.3

Current prevalence and trends in smoking habits:

The HI survey also reflects WHO data on long term health effects of tobacco use, reporting that 32% of smokers and 39% of ex-smokers suffer from long-term illness and chronic health problems, compared with 27% of never smokers.4 Year on year, the HI Survey identifies 25–34-year olds as the age group most likely to smoke, and the proportion of smokers in this group has experienced a 4-point increase to 24%, significantly higher than the national average. 4 Smoking prevalence by age and gender is illustrated in Figure 1 and of note highlights the persistent high smoking rates within young adults, particularly males, and the decrease in smoking prevalence among older adults.

The use of electronic nicotine delivery systems (ENDS), often referred to as e-cigarettes or ‘vapes’ is increasingly prevalent, with a major expansion of this market in Ireland over the past two decades. Overall, 6% of the population reported using ENDS regularly, with the highest use reported in those under the age of 25 (11%).4 ENDS are highly variable, without a strict regulatory framework, and at present there is no definitive research on the long-term impacts of ENDS use, or second-hand exposure. As the popularity of ENDS grows, there is concern about their use in younger people. The Public Health (Tobacco Products and Nicotine Inhaling Products) Bill 2023 is currently before Dáil Éireann, and proposes to introduce a regulatory framework for the retail sale of ENDS, termed ‘nicotine inhaling products’. These measures focus on reducing access to ENDS for children by restricting the sale of these products, and plans to prohibit advertisement of ENDS around schools and on public transport.

The European Schools Project on Alcohol and other Drugs (ESPAD) Ireland 2019 Report5 provides information about substance use among Irish teenagers attending secondary school, and reported that the decline in smoking has halted in Irish teenagers for the first time in 25 years. This correlated with a higher prevalence of e-cigarette use among Irish teenagers than smoking tobacco, with 39% of 15- to 16-year-olds reporting having used ENDS, compared with 32% smoking tobacco. There are concerns about the potential role of ENDS providing new routes into nicotine addiction, with 68% of adolescents in a 2019 study reporting they had never used tobacco prior to first use of e-cigarettes.6

In the adolescent population, e-cigarettes are rarely cited as a smoking cessation technique, with only 3% of adolescents reporting quitting smoking as the reason for first using e-cigarettes.6 This contrasts with the high ENDS use as a smoking cessation tool in adults; the HSE National Stop Smoking Guideline reports 38% of people choosing e-cigarettes as a quit smoking aid in 2019.7

Tackling tobacco use

Tackling tobacco use has become a priority for government policy makers worldwide. In 2008 the WHO implemented the MPOWER policy as a worldwide tobacco control strategy, aiming to assist in the country-level implementation of effective interventions to reduce the demand for tobacco.

In 2004, Ireland became the first country to pass a smoke-free law8, and furthermore in 2021 was recognised by the WHO as a global leader in tobacco control.

The Department of Health has set the goal of being tobacco-free by 2025, defined as a smoking prevalence of less than or equal to 5%. However, as the HI Survey shows, ongoing improvements in smoking cessation policy and practise are required to maintain progress towards this goal.

As demonstrated in the HI Survey 2022, a large proportion of smokers suffer from chronic illness (4) which in turn often results in hospital admissions and prolonged inpatient stays. This was demonstrated in a 2016 study which attributed 309,117 beddays to smoking related illnesses. The HSE recommends that each patient encounter in the hospital setting is used as a valuable opportunity for a brief intervention to discuss smoking cessation.

In our service, this is particularly applicable in the Rapid Access Lung Clinic, a service for diagnosis and treatment of patients with suspected lung cancer. A recent analysis highlights the benefit to overall survival of stopping smoking at any time for a patient with lung cancer.

Effective smoking cessation framework

There is precedent for the implementation of smoking cessation frameworks within healthcare settings, as evidenced by the success of the Ottawa Model for Smoking Cessation (OMSC) which was first developed in the early 1990s. The OMSC is a validated, evidence-based process to embed comprehensive smoking cessation treatments and support as an integral aspect of routine patient care. Since its inception the OMSC has continued to expand. In 2020 the OMSC had been implemented in over 500 outpatient, inpatient and primary care sites across Canada. A 2015 study reported that 35% of patients who received the OMSC interventions were smoke-free at 6 months, and had a 40% reduction in risk of death over 2 years.11

In 2017, the OMSC was adapted in the Greater Manchester Area in the UK as the CURE project; a comprehensive secondary care treatment program for tobacco addiction. The CURE project has been shown to be cost-effective, with a highly significant return on investment.12 The CURE project estimates a 50% reduction in readmissions at 30-days (3,273 admissions), and a reduction in re-admissions at 1 year from 38.4% to 26.7%. This project is estimated to save 30,880 bed days per year in the Greater Manchester Area. Furthermore, it has been proven to deliver high-quality care for patients by providing access to highly effective interventions and providing individualised smoking cessation treatment.13 The success of the CURE project has led to a commitment from the NHS that by 2023/24 all active smokers admitted to hospital will be offered NHS-funded tobacco treatment services, based on the successful and favourable results from the OMSC and CURE models.

Local data

In Galway University Hospital we conducted a review of current smoking prevalence and smoking cessation services. An initial chart review revealed that 19.7% of audited patients were active smokers; overall in line with the national data. However, initially, only 64.4% of patients had smoking status documented, and only 13% received brief advice, with the same percentage referred to smoking cessation services. A standardised smoking cessation proforma was implemented on a pilot ward as part of the admission bundle, aiming to document smoking status on admission to hospital and encourage brief advice, and, in addition, all identified smokers were referred to smoking cessation services with their consent. These simple interventions including the introduction of a standardised approach to identification of smoking status and an optout referral of active smokers to smoking cessation services significantly improved practice. This project was supported by encouragement of nursing staff during the daily safety-pause, and a poster campaign on the pilot ward. During the pilot programme, smoking documentation rate increased to 85.7%, and 95% of tobacco users were referred to local smoking cessation services, a significant improvement from the reported pre-intervention results

HSE National Stop Smoking Guideline

In Ireland, the HSE implemented the National Stop Smoking Guideline (NSSG) in 20227 aimed at improving the identification and treatment of tobacco addiction across all healthcare settings. Healthy Ireland reports that 29% of smokers are either trying to quit or are actively planning a stop date.4 However, only 18% of smokers who saw their GP over a 12-month period discussed methods of smoking cessation, a decline of 50% compared to data from 2019.4

The NSSG recommends that all healthcare professionals ask and document an individual’s smoking behaviours, and, in turn advise all active smokers about the harms of smoking and the benefits of cessation. Healthcare professionals should discuss the individual treatment needs and preferences, and advise that making an unsupported quit attempt is less effective than using recommended supports. This is supported by WHO data which demonstrates that brief advice from health professionals can increase quitting success by up to 30%, while intensive advice increases the chance of quitting by 84%.

The NSSG identifies asking about smoking behaviour and offering advice to quit as a key element of health behaviour change that should be utilised by healthcare professionals in their day-to-day practice. Sometimes referred to as a ‘teachable moment’, these conversations aim to motivate individuals to adopt risk reducing health behaviours. The 5 A’s model (figure 2), recommended by the Centre for Disease Control (CDC) and WHO, summarises the activities that a healthcare provider can do within 3-5 minutes during a consultation. Multiple studies have shown the benefits of a brief intervention program, delivered by staff who are appropriately trained, with a statistically significant difference in smoking cessation and continued abstinence.14

The British Thoracic Society (BTS) and the National Institute for Health and Care Excellence (NICE) recommend that all frontline healthcare staff should receive training to identify smoking status and to offer very brief advice, as well as the local referral process for behavioural support.15,16

Additional options for behavioural support include individual or group counselling, telephone or text-message support. Currently, behavioural support is available through specialist smoking cessation officers, both in hospital and community-based facilities, who can also provide prescription for NRT if required. Novel methods of delivering counselling for smoking cessation have been developed including the digital counselling service ‘Florence’, an artificial intelligence bot developed by the WHO. Florence is a 24/7 virtual health worker, capable of providing brief conversations by voice or text, and can signpost patients to other digital cessation programmes in their country, and can found at https://www.who. int/campaigns/Florence. This technology was developed in 2021, primarily aimed at overcoming the barriers arising from the COVID-19 pandemic such as easy access to smoking cessation services. The HSE has also developed a digital cessation service, and offers a 28-day plan including personalised daily support via email and text message through the website, with a personalised web page to track progress.

For patients who wish to use pharmacological therapy in combination with behavioural supports, the NSSG recommends that combination NRT treatment or NRT monotherapy should be prescribed. NRT is available in multiple forms and prescription can be tailored to the patient’s preference (figure 3). A recent Cochrane review confirmed the effectiveness of NRT in smoking cessation.17


The development of an effective smoking cessation framework in the hospital setting has been proven by the Ottawa Model (Canada) and the CURE project (UK) to be a cost-effective intervention, which benefits patients at any stage of a disease course, and in addition can equal the benefit of costly pharmacological or surgical interventions. Recent data indicates a slowdown in the momentum towards the target of a tobacco-free Ireland by 2025. Meeting this goal is dependent on accelerating progress with smoking cessation programs across all healthcare settings. Additional challenges are also appearing, for example, the smoking habits of Irish people are evolving with the increasing popularity of e-cigarettes and this will require the adaptation of current smoking cessation practise and legislation to tackle these changes particularly amongst younger people. Providing standardised clinical care to patients in healthcare is challenging, due to the diversity in environments of care and patient presentations. However, there is an opportunity during all patient encounters to provide a brief intervention and in turn direct patients to appropriate smoking cessation treatments. Improvements in smoking cessation services in Ireland are dependent on adequate access to behavioural and pharmacological supports for all patients, irrespective of chronic illness or socioeconomic status.

At present, we risk reversing the gains which have been made to date in Ireland towards the goal of a tobacco-free nation. The impact of the COVID-19 pandemic, novel nicotine delivery systems, and the rise of tobacco addiction among young people cannot be underestimated, and additional funding and training of healthcare professionals is required for smoking cessation services to maintain momentum in tackling tobacco addiction in Ireland.

References available on request

Written by Dr S Griffiths, Dr D Breen, Department of Respiratory Medicine, Galway University Hospital

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