Melanie Perry TDP Lecture

Motivating patients to accept referral to tobacco dependency services: Melanie Perry

Friday, July 14, 2023

We welcome Melanie Perry to Respiratory Futures. Melanie has a wealth of experience in tobacco dependence services and is a project manager at the British Thoracic Society.

In this article we explore some of the ways to improve communication between healthcare professionals and people who are smokers.


Melanie, please can you start by telling us your background in helping people with tobacco dependence?

My background is nursing, during my time working within primary care my role became more focused on health promotion and prevention. In 2005, I took on the role of pregnancy lead for the Local Stop Smoking Service (SSS) and my career in tobacco dependency began.

In 2008, I joined Leicester City SSS to become the acute lead, starting from scratch and setting up a service within UHL (University Hospitals of Leicester)

I implemented a system for capturing patients that wanted support to stop smoking, developed an electronic referral system and ensured NRT was available on formulary. I delivered VBA training to over 2000 healthcare professional over a 12-month period which saw referrals increase significantly.


How important is it for healthcare professionals to feel confident talking to patients about their smoking?

All patients that smoke have equal rights to the best available evidence-based treatments for any clinical condition, and that includes treatment for their tobacco dependence.

We know that the majority of patients we see in hospital with a tobacco dependency understand the health implications and want to stop. The challenge is to encourage people to accept the treatment available, leading to a successful quit attempt, followed by a long term quit beyond the hospital stay.

We often talk about teachable moments and smokers who are admitted to hospital is a great example. People will be unable to smoke while receiving care and it is vital that all healthcare professionals are confident and have the skills to talk openly to people about their smoking. This approach ensures the person’s tobacco dependence is well managed while an in-patient and maximises the opportunity to encourage a quit attempt.


In your experience, what are some of the barriers to good communication?

A project by NIHR Applied Research Collaboration North East and North Cumbria has provided useful insight through some first phase briefings, including:

- Healthcare professionals reported increased anxiety and concerns about increases in workload which then generated a hesitancy to engage smoking patients in important conversations about their tobacco dependence

- The perception of some healthcare professionals that smoking is a lifestyle choice and not an addiction.


What impact can poor communication have?

For patients, they can feel:

- Judged

- Anxious

- Guilty - still smoking despite knowing the health impacts

- Vulnerable

- Confused - information overload

- Frustrated - asked 100 times already, but may not have been offered support

- Worried about the reaction of HCP

- Previous negative experience from quitting and/or from a response by a HCP


For healthcare professionals:

- Uncomfortable/anxious/hesitant

- Lack of confidence/overconfident

- Lack skills/knowledge/time

- Can feel smoking status is less relevant than other clinical conditions

- Pre-conceived ideas around smoking

- Frustrated

- Worried relationship may be tarnished

- Influenced by past experiences


You are focused on describing tobacco dependence and use the word addiction. Why is this language so important?

Smoking results in an addiction to nicotine but this can be managed as part of an effective treatment programme. Most people do so because of their addiction, not because they are choosing to smoke.

People need help to understand their addiction and healthcare professionals are ideally placed to shift this emphasis to a medical management model. People take notice of their clinicians, and we know that it is incredibly difficult for people to stop smoking without support and a nicotine containing product.

Clinically, it is so important to ask your patients about their smoking. Carried out with the right attitude and language, asking will not harm your relationship with them, and in fact they will expect you to ask.


What does good communication look like?

Patients should feel:

-  Understood

- Reassured

- Supported

- Invested

- Motivated

- Confident

- Positive

- Hopeful

Healthcare professionals should feel:

- Confident

- Informed

- Supported

- Unbiased

- Relevant

- Believe in the patient’s ability to stop

- Assured in their ability to ask

- They have the time to treat and afford this the necessary priority

Good communication shifts attitudes to smoking and changes the culture. This then allows a more positive outcome and forward looking communication.

Most importantly, communicate positively:

- Talk about medical management, which moves away from the idea the person is choosing to smoke.

- Relate benefits back to their clinical condition and emphasise the role stopping smoking could play in managing their disease.

- Treatments for tobacco dependence work.

- Nicotine replacement is safe and there are established pathways to use.

- Never give up on giving up.

Avoid being negative and try not to focus on:

- People having to stop

- Needing to use willpower

- Failure / blame if a quit attempt is unsuccessful

- Needing to change behaviour, or suggest it is a lifestyle choice to stop


Are there any specific strategies that people can adopt?

Take 30 seconds to save a life – the 3 As.


Ask and record smoking status.

Simply ask “Do you smoke”


Advise about health benefits.

“Stopping smoking is the best thing you can do for your health”


Act on responses. Build confidence, offer information and refer on to a specialist service.

“I’m going to make sure that you receive the best treatment and support for your tobacco dependency”

“I am going to arrange for you to see a specialist who can help to support you. Is that OK?”


What are the top 3 things you would like all healthcare professionals to do?

  1. Talk to all your patients that smoke about their tobacco dependency; you can’t assume someone else will do this.
  2. Use positive language and messages; we have evidence-based treatments that work.
  3. Be an ambassador and support those around you to build their confidence.



If you would like to read more about the evidence base for treating tobacco dependence, here are some resources you may find useful.

Respiratory Futures – Training and Education opportunities

NICE Guidance -

NCSCT – E-learning modules

Supporting the NHS long-term plan: An evaluation of the implementation and impact of hospital-based tobacco services. - ARC (