Prisons and Criminal Justice
Settings Stop Smoking Training:
Knowledge and Skills
Competency Framework
Contents
Executive Summary
1
Introduction
1
Complexities of the Setting
2
Levels of Intervention: A Tiered Approach
5
Structure/Model for Delivery
15
Learning Outcomes Checklist
18
References
19
Useful Links and Contact Details
20
Acknowledgements
Stephen Woods
North West Tobacco Control Co-ordinator Prisons and
Criminal Justice Settings
Michelle Baybutt
Intervention Manager UCLan
Susan MacAskill
Senior Researcher Institute for Social Marketing
University of Stirling
Douglas Eadie
Senior Researcher Institute for Social Marketing
University of Stirling
Jennifer McKell
Research Assistant Institute for Social Marketing
University of Stirling
Lisa Halliday
Stop Smoking Advisor Primary & Secondary Prevention
Services Lancashire Care NHS Foundation Trust
Miriam Bell
Fag Ends Performance and Delivery Manager Roy
Castle Foundation
Lisa Gill
Training and Youth Advocacy Lead Roy Castle
Foundation
Tina Williams
Head of Training and Development Tobacco Free
Futures
The project is part of a portfolio funded by the Department of Health and led by
the UK Centre for Tobacco Control Studies (UKCTCS www.ukctcs.org):
a UK Public
2
Health Research Centre of Excellence and a strategic partnership of nine
universities involved in tobacco research in the UK.
November 2011
EXECUTIVE SUMMARY
This document and an accompanying ‘Practitioner Summary’ are part of the delivery of a
Department of Health funded Public Health Inequalities Demonstration project, one of 6 such
programmes nationally. This project focuses on the role of a Regional Tobacco Control Coordinator:
Prisons and Criminal Justice Settings which was established to look toward the organisational and
systems perspectives across prisons, probation services, and police custody in relation to tobacco
control and stop smoking support and treatment in the North West 1. The project is part of a
portfolio funded by the Department of Health and led by the UK Centre for Tobacco Control Studies
(UKCTCS www.ukctcs.org): a UK Public Health Research Centre of Excellence and a strategic
partnership of nine universities involved in tobacco research in the UK. The findings and
recommendations being used to focus on ‘what works’, recognising complexities such as the
constraints within systems for practitioners; challenges of working across organisational boundaries;
and the needs of differing audiences, such as commissioners and providers.
INTRODUCTION
This document will outline the opportunities within Prisons and the Criminal Justice Setting (CJS) for
effective and consistent delivery of stop smoking services. It will highlight the public health
opportunities and benefits of delivering targeted services with a particular focus on the consistent
delivery of training. The document draws on both the original HDA skills and Competency framework
(Health Development Agency, 2003), NICE guidance (NICE, 2008) and the more recent work from the
NHS Centre for smoking cessation training (NCSCT, 2010) to support the consistent delivery of
training across the North West. This settings specific framework maintains the original ethos of
encouraging staff to reflect on their own work and professional standards and supports them in
planning their own professional development. This places a level of responsibility on the individual
to identify skills knowledge and learning and to build upon it.
Smoking and Smoking Cessation Issues in Prisons and the Criminal Justice Settings
The initial project mapping activity highlights a number of opportunities across the criminal justice
system to support and develop the delivery of stop smoking services and illustrates a training
framework for delivery across the prison and criminal justice settings.
The North West Prisons (16) have established stop smoking services with a variety of delivery
models. There is scope to consolidate good practice and provide consistency across the prison and
criminal justice system. Further, the probation setting offers access to a wider group of potential
quitters many from areas of significant deprivation, who present with numerous risk factors and
who experience clear health inequalities (DH, 2003).
1
UCLan http://www.healthysettings.org.uk/
1
In addition, there are high levels of smoking amongst prisoners (approx. 80%) (Social Exclusion Unit,
2002). It is reasonable to consider that offenders in the probation system have a similar if not
equally high rate of smoking coupled with the same contributory factors such as high levels of
mental health conditions, substance use and educational limitations (Social Exclusion Unit, 2002). It
is important that attention is given to the prisoner pathway on release particularly those released on
licence to help prevent successful quitters relapse. This is supported by evidence from a number of
studies across the wider Criminal Justice System. For example, a 2007 survey of offenders on the
probation caseloads in Nottinghamshire and Derbyshire revealed that 83% of probationers were
smokers compared to only 22% of the general population (Brooker, et al 2009). In addition to this
63% of detainees in police custody in London reported dependence on cigarettes in a 2007 survey
(Payne-James, et al 2010).
Prisons as a Healthy Setting and Public Health Opportunity
WHO have defined ‘settings for health’ as “the place or social context in which people engage in
daily activities in which environmental, organisational and personal factors interact to affect health
and wellbeing” (WHO, 1980; WHO, 1986; Dooris 2006). Establishing a holistic, multifaceted and
multidisciplinary approach that focuses on the integration of health promotion and sustainable
development (Dooris, 2006) of smoking and tobacco control issues in the offender settings presents
an opportunity to address offender health and thus tackle health inequalities.
It is clear that prisons and the wider criminal justice setting can be seen in this way and are indeed
both a place and a social context albeit in a captive or controlled environment. The opportunities for
health promotion are evident as the vast majority of the prison population are from deprived
backgrounds, have particular needs and are in many instances engaged in a variety of risk taking
behaviour/s. It is important to highlight that people in custody are members of and move back into
the wider community, thus taking with them their health issues etc.
COMPLEXITIES OF THE SETTING
Understanding the complexities of delivering stop smoking services in the prison setting is a
fundamental element to training at all levels as there are a number of barriers and facilitators to
delivering stop smoking services in prisons.
The project mapping activity identified a number of keys issues in stop smoking service delivery:

A variety of delivery models exist, providing creative solutions to access to stop smoking
services. However there are also a number of barriers or challenges to delivery. In
establishments where the community teams deliver stop smoking sessions; the benefits
include dedicated time by staff whose core role is delivery of stop smoking services. The
converse to this, is staff are less familiar with the complexities of the prison system and
culture. The potential is for prisoners to abuse the system and use of NRT. Where prison
employed health care staff or gym staff deliver the sessions this is less likely to occur due to
2
their knowledge of the system and culture. However, staff in such roles may not have
dedicated time or be able to prioritise the delivery of stop smoking sessions resulting in
potential cancellation of sessions;

Capacity to address waiting lists: all North West prisons have waiting lists ranging from 2-3
weeks up to 12 weeks, irrespective of provider;

Those prisoners that did not attend (DNA’s) in some establishments present a problem
primarily due to difficulties escorting prisoners to sessions or appointments.

In some prisons particularly local and remand prisons, and including women’s prisons, the
turnover of the population presents a challenge to delivery of a structured stop smoking
programme. As a result lower numbers access services;

Most prisons have mechanisms in place to monitor the distribution and use of patches in
most instances this is on a patch for patch return basis – coupled with regular CO
monitoring; helps alleviate some of the issues related to NRT abuse. However in larger
prisons the distribution and monitoring through pharmacy is more complicated and weekly
supplies are more frequent. Random CO monitoring is utilised in some establishments to
varying success providing an additional level of control;

Tobacco and NRT are used as currency and as such, there is the potential for bullying to take
place. This is an important factor in understanding the role of tobacco in the prison
environment;

Access to a range of NRT and stop smoking support products is apparent. It is limited to
patches in many establishments although some do actively provide access to Micro tablets,
nasal sprays, inhalators and in a small number Champix. However access to Champix is less
available and is often only considered in instances where a prisoner has already started on a
programme prior to coming into custody or has been transferred part way through a course
of treatment. Some prisons do not provide access due to the indicated additional suicide and
mental health risks. There is clearly a need to provide some consistency to the products
available across the system as some prisons have cleared items through security others have
not so a prisoner moving within the prison system may not have consistent access to
products.
The Recognised Need for Training Standards
This document draws on existing training guidance and applies it to the Prison and Criminal Justice
setting. The Health Development Agency (HDA, 2003) launched the first national standard for
training in smoking cessation treatments. These standards aimed to improve the effectiveness of
services by raising the quality and improving the delivery of training to stop smoking advisors. This
was further supported in 2005 by the publication of a Skills and Competencies framework for trainers
of smoking cessation treatments (HDA, 2005). More recently the NHS Centre for Smoking Cessation
and Training published an updated document the Learning Outcomes for Training Stop Smoking
Specialists (NCSTC 2010). This takes into account the clinical, policy and research developments that
3
have taken place since the publication of the original document. The complexities of delivering
services in a prison environment should be included as a core element of the training. It is essential
that any setting specific training focuses on individual client group needs, reflecting on the above
barriers and facilitators to service delivery. Much of what stop smoking services in the community
would advocate helping support quitters needs redefining due to the constraints of the prison
system.
Offender Needs
‘Acquitted’: Best Practice Guidance for Developing Smoking Cessation Services in Prisons (DH, 2003)
outlines the basic principle underpinning health provision in prisons. Particularly that services should
be based on need and offered to an equivalent standard to those delivered in the community (DH,
2003; DH, 2002). The importance of understanding the role smoking has in the lives of prisoners in
particular relief from both boredom and stress is further compounded by increased stress points and
the lack of variety in diversionary activities in prison (DH, 2003). The following table provides a
summary of some of the key issues relating to the needs of offenders.
Table 1: Offender Needs and Issues

High risk group

Literacy

Previous lifestyle experiences

Isolation

Boredom – access to diversionary activities – incentives

Long periods locked in cells

Culture and masculinity – men’s health

Mental health and wellbeing – depression anxiety – confidence self-worth – emotional
wellbeing /stress /coping mechanism

Bullying – culture of violence

Identity fitting in

Tobacco and NRT as currency

Staff smoking

Control over the frequency/ability/affordability to smoke
4
LEVELS OF INTERVENTION: A TIERED APPROACH
There are differing levels of intervention across the system and a need to acknowledge the
complexities of delivering stop smoking services to individuals in this setting. Skilling up staff across
the system can increase knowledge and skills, enhance service delivery and increase workforce
capacity by defining appropriate and structured levels of intervention and support (NCSCT, 2010).
A tiered approach to the delivery of stop smoking training fits with national recommendations (HDA
2003/5;-NCSCT, 2010; NICE, 2008). The four distinct levels:
 Level 1 basic awareness of the determinants of health, risk factors and the impact on health
focusing on smoking as a worked example;
 Levels 2A and 2B which cover brief intervention and delivery of advice and support
respectively;
 Level 3 which is specialist stop smoking support.
Tiered Approach: Potential Roles for Delivery
This framework is designed to support a joined up approach to the delivery of stop smoking services
acknowledging that staff across the prison and criminal justice system haves a role in delivering a
consistent, robust and truly integrated service.
Table 2 clarifies the learning outcomes expected at each tiered level in line with both the original
guidance (HDA, 2003/5) and update documents from the NHS Centre Smoking Cessation Training
(NCSCT, 2010). It provides an indicative list of key players in the delivery and support of stop
smoking services.
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Table 2: Learning Outcomes
Level 3
Specialist
Advisor
Level 2 B
Support and
Advice
Level 2 A
Brief
Intervention
Level 1
Awareness
raising
GP’s; Nursing
staff; Health care
teams; Nursing
staff / HCA’S;
Community SSS
Levels of Intervention: Learning Outcomes
Knowledge; smoking in the population; smoking and health;
why stopping smoking can be difficult; smoking cessation
treatments; the wider context
Practice; Assessment; planning behavioural support; Delivery
of behavioural support; group based behavioural support
(Inc. NCSTC accreditation)
Gym Staff
Nursing staff /
HCA’S other
health care staff
Discipline staff







Smoking demographics
The effects of smoking and stopping smoking
Smoking cessation treatments and their outcome
Assessment
Pharmacotherapy
Behavioural support
Treatment programme monitoring and continuing education
(Inc. NCSTC accreditation)
Gym Staff
Health care staff
Discipline staff
Prisoners








Assessment and recording of smoking status
Assessment of readiness to quit
The health risks of smoking and the benefits of quitting
Reasons why stopping smoking can be difficult
Treatments to help with stopping smoking
Referral to local services
Wider Context
Understanding of offender issues
All staff; could be
induction based?
Discipline Staff
Gym staff
Education and
Work shop staff
Prisoners
Partners and
Family Members




Awareness of the key determinants of health
Understand these in relation to the offender population
Be able to identify key risk factors in relation to
Health - alcohol, Physical activity and Healthy weight,
smoking, mental health and well being
Explore smoking as a worked example – outlining the
key impact on health list the major life and non- life
threatening diseases to which smoking contributes
Describe the main health benefits of cessation
Describe the harmful effects of passive smoking
Be able to identify Routes to sign post individuals
for on-going advice and support
Provide Very Brief Advice (VBA)







Tiered Approach: Detailed Learning Outcomes
The following provides detailed explanations of the core learning outcomes at each tiered levels.
Each descriptor builds on the previous level; all staff can be trained to provide level 1 intervention
staff across all disciplines could be trained to level 2B and potentially level 3:
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Level 1 – Basic Awareness Raising
Basic awareness raising can be delivered by individuals who work with a range of offenders and with
a variety of needs but whose primary role is not necessarily within health for example gym or
residential staff.
1.0 Level of intervention
This level aims to raise awareness of the determinants of health and maximise the potential for
health promotion interventions that support healthy relationships, positive health and well-being
and promote personal responsibility. It is important to ensure that the full range of staff involved
with offenders are appropriately equipped with the skills, knowledge and support to provide basic
health information Very Brief Advice (VBA) and sign post individuals into appropriate services.
1.1 Core competencies at this level





Awareness of the key determinants of health; and, understand these in relation to the
offender population;
Identify key risk factors and benefits in relation to health – alcohol, physical activity and
healthy weight, smoking, mental health and wellbeing;
Explore smoking as a worked example - outlining the key impact on health listing the major
harmful and life-threatening diseases to which smoking contributes
Describe the harmful effects of passive smoking;
Provide Very Brief Advice (VBA) and identify routes to sign post individuals for on-going
advice and support.
Level 2 A – Brief Intervention
This level is delivered by individuals who work with a range of offenders with a variety of needs but
whose primary role may or may not be in health for example healthcare advisors, gym staff and
residential staff.
To raise awareness of the determinants of health and maximise the potential for health promotion
interventions that support healthy relationships, positive health and well-being and promote
personal responsibility, it is important to ensure that the full range of workers involved with
offenders are appropriately equipped with the skills, knowledge and support to provide brief
intervention and where appropriate referral to services.
Core Competencies at this level (NCSCT, 2010)
2A.1 Assessment and recording of smoking status;
• Ask about smoking in an appropriate way, to elicit an accurate response
• Record status and action taken on an appropriate computer or paper based system
2A.2 Assessment of readiness to quit;
 Ask appropriate questions to assess readiness to make a quit attempt
 Assess willingness to use appropriate treatments
7
2A.3 The health risks of smoking and the benefits of quitting;
 List the major life-threatening and non-life-threatening diseases caused by
 Describe the effects of passive smoking on adults and children
 Explain the benefits of quitting smoking
 Describe compensatory smoking in relation to reducing frequency of smoking or switching
to lower tar cigarettes
2A.4 Reasons why stopping smoking can be difficult;
 Describe the main features of the tobacco withdrawal syndrome
 Dispel common myths about the perceived benefits of smoking
 Describe the social context and psychological effects of tobacco use
2A.5 Treatments to help with stopping smoking;
 Describe the principles and effectiveness of the specialist services involving behavioural
support and medication
 Describe the various forms of medication and their use
 Identify commonly used treatment options that have not been found to be effective
 Explain the importance of directing smokers to treatments with proven effectiveness
 Respond appropriately to client enquiries on treatment options
2A.6 Referral to local services;
 Describe the local services and how a client can access them or how a referral
 can be made
 List the pros and cons of referring smokers to local services and of providing brief one-off
advice
 Present the local service to clients in an appropriate and positive way
2A.7 Wider context;
 Describe the role of brief interventions in local and national service provision and targets
 Briefly describe the national policy framework
Level 2 B – Support and Advice
This level is delivered by individuals who work with a range of offenders with a variety of needs
whose primary role may or may not be in health but, who have been selected and trained to provide
additional support to those interested in stopping smoking – these may be members of healthcare,
discipline staff, gym staff or offender health trainers and listeners.
To raise awareness of the determinants of health and maximise the potential for health promotion
interventions that support healthy relationships, positive health and well-being and promote
personal responsibility, it is important to ensure that the full range of staffs involved with offenders
are appropriately equipped with the skills, knowledge and support to provide brief intervention,
appropriate support and advice and where necessary referral of those needing additional clinical
support or treatment.
Staff delivering at this level will have received core training in brief intervention as described in level
2A in addition to this they will also have covered the following additional aspects:
8
(N.B. Those supporting a smoker to quit should be trained according to the NCSCT Training
Standard and should obtain full NCSCT Certification. 2)
2B.1 Smoking demographics;
 Describe smoking prevalence and patterns as functions of age, gender, ethnic origin and
social class
 Understand the local smoking prevalence and patterns where known, and the implications
of this to their work
2B.2 The effects of smoking and of stopping smoking;
 Describe behavioural and pharmacological determinants of smoking behaviour
 Describe the perceived benefits of smoking
 Describe the common and less common tobacco withdrawal symptoms and their duration
 Use this information appropriately in treatment
2B.3 Smoking cessation treatments and their outcome;
 Show awareness of the existing treatments
 Understand how smoking cessation methods are evaluated and how the results are reported
 Describe typical long-term outcome results of the main treatment methods, and of the
treatment method taught at the course
 Describe a typical relapse curve
2B.4 Assessment;
 Assess a client’s nicotine dependence using an appropriate method
 Assess a client’s commitment to the present quit attempt and to attending treatment
 Describe the relevance to treatment of past quitting history and smoking characteristics
 Demonstrate the use of the CO monitor as a motivational tool and as a means of assessing
and validating smoking status
2B.5 Pharmacotherapy;
 Describe the full range of medications available, their use, availability and cost, cautions and
Contra-indications and side effects
 Explain medications to clients in an accurate and positive way, and help them in choosing
one
 Alleviate fears of medication (side effects, cancer, dependence potential)
 Create realistic expectations of the medication effects
 Effectively liaise with prescribers (where appropriate)
2B.6 Behavioural support;
 Maximise commitment to the target quit date
 Apply appropriate behavioural support strategies within the treatment programme
 Respond to common questions and issues raised by smokers
 Describe common barriers to quitting
 Address problems with patient’s motivation, strong withdrawal reactions, and adherence to
treatment
 Describe when and how to end treatment
 Discuss relapse situations and known predictors of relapse
2
www.ncsct.co.uk
9

Deal appropriately with lapses and with full relapse during treatment
2B.7 Treatment programme;
 Describe a typical treatment programme, its aims, length, how it works and its benefits
 Describe and deliver the content of typical introductory, mid-treatment, and final sessions
 Describe local policies and procedures regarding logistics of treatment
2B.8 Monitoring and continuing education;
 Describe local and national monitoring requirements
 Describe the local system for monitoring a client’s progress
 Describe the local system for organising end-of-treatment and long-term follow-ups and
keeping records on throughput, outcome, and client characteristics
 Identify professional resources for smoking cessation specialists
2B.9 Group-based behavioural support;
 Learning resources and training course content should result in Stop Smoking Specialists
being able to do the following:
Planning behavioural support in (closed) group contexts;
 Assess a client’s suitability for group support
 Plan, organise, establish and run a stop smoking group
 Manage problems of co morbidity (psychological and physical) within the group
appropriately
Maximising motivation to quit within the (closed) group context;
 Stimulate and facilitate supportive group discussions
 Apply techniques, such as group tasks or placing of chairs, to reinforce group
interaction and enhance mutual group support and/or bonding
 Encourage clients to make public promises/contracts with other group members
 Foster a sense of responsibility to the group
 Encourage group members to compare their CO readings
 Facilitate communication of group member identities (e.g. using name badges,
encouraging client’s to talk about themselves)
 Report on missing members appropriately so as to maintain group motivation
Supporting activities in the (closed) group context;
 Facilitate choice of medications in a group context
 Encourage sharing of experiences of medication use
Communication in the (closed) group context;
 Describe the content of group support sessions and ways in which group
processes can sustain or enhance motivation to stop smoking, and to help create
accurate positive treatment expectations
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Level 3 – Support and Advice / Specialist Support – Additional Clinical Input
Delivered by individuals who work with a range of offenders with a variety of needs but whose
primary role is likely to be in health (In practice staff trained to this level are likely to be health
workers however in some circumstances other staff could be trained to specialist level).
To raise awareness of the determinants of health and maximise the potential for health promotion
interventions that support healthy relationships, positive health and well-being and promote
personal responsibility, it is important to ensure that the full range of workers involved with
offenders are appropriately equipped with the skills, knowledge and support to provide brief
intervention, appropriate support advice and treatment.
At this specialist level, staff will be equipped to support the development and delivery of a robust
stop smoking service and will provide the expertise, skills and knowledge base to support staff across
the system. They will be ‘champions’ with a lead role in service development and delivery.
Staff delivering at this level will have received core training in brief intervention support and advice
as described in level 2A and 2B.In addition to this they will also have covered the following additional
aspects:
(N.B. Those supporting a smoker to quit should be trained according to the NCSCT Training
Standard and should obtain full NCSCT Certification3)
(The following is taken from the NHS Centre for Smoking Cessation and Training document ‘Learning
Outcomes for Training Stop Smoking Specialists’. It provides the basic outline for those working at
level .3) (NCSCT, 2010.)
3.0 Knowledge
Learning resources and training course content should result in Stop Smoking Specialists
being able to do the following:
3.1 Smoking in the population;
 Describe smoking prevalence and patterns of smoking and smoking cessation as functions of
demographic characteristics such as gender, age, ethnicity and socio-economic status
 Describe smoking prevalence and patterns of smoking and smoking cessation in special
groups, such as pregnant smokers and those with mental health problems
 Describe changes in smoking and smoking cessation patterns over time and across different
demographic groups
3.2 Smoking and Health;
 List the major life-threatening and non-life-threatening diseases to which smoking
contributes
 Describe the health benefits of cessation quantify the increased risk of premature death
from smoking and the benefits of cessation at different ages
 Describe the harmful effects of smoking during pregnancy and breast feeding
 Give an accurate indication of the limited potential beneficial effects of smoking
3
NCSCT, 2010 www.ncsct.co.uk
11


Describe the harmful effects of passive smoking
Describe effects of stopping smoking on dosages of drugs used to treat conditions such as
psychotic disorders
3.3 Why stopping smoking can be difficult;
 Accurately describe the process of stopping smoking in a way that reflects the extent to
which attempts to stop can be arrived at suddenly or gradually, the importance of avoiding
‘lapses’,
 The factors that promote and deter quit attempts and factors that protect against and
promote relapse
 Explain what is meant by tobacco addiction and nicotine dependence and how these
develop
 List known nicotine withdrawal symptoms and their natural time course
 Describe the common reasons smokers give for why they smoke and how far these reflect
the true effects of smoking
 Describe environmental, socio-demographic and psychological factors associated with
cigarette addiction
3.3 Smoking cessation treatments;
 Describe the principles, and long-term and short-term effectiveness, of behavioural support
(individual and group-based)
 Identify potential difficulties associated with providing group-based support, such as patient
recruitment and organisational logistic demands, and how these can be addressed
 Describe the full range of evidence-based medications available to aid smoking cessation,
including their efficacy; correct use; contra-indications and cautions, drug interactions, sideeffects; and relevant clinical guidelines
 Explain why complementary therapies and unproven commercial treatment programmes for
smoking cessation should not be made available on the NHS
 Show understanding of the principles and methodology of measurement of biomarkers of
smoking, such as carbon monoxide (CO) and cotinine
3.5 The wider context;
 Show awareness of the contribution of smoking cessation to public health and to reducing
health inequalities
 Demonstrate understanding of the role of smoking cessation in wider tobacco control
strategies
 Describe the cost effectiveness of smoking cessation interventions compared with other lifesaving clinical interventions
3.6 Practice
 Learning resources and training course content should result in Stop Smoking Specialists
being able to do the following:
3.7 Assessment;
 Assess a client’s current commitment, readiness and ability to quit throughout the quitting
process
 Assess a client’s past smoking behaviour, including past history of quit attempts
 Assess a client’s current self-reported and CO-validated smoking behaviour and deal
appropriately with any discrepancies that may arise between these
 Assess a client’s level of available social support, including assessment of the client’s
contacts who smoke
12



Assess a client’s degree of nicotine dependence using validated tools such as the Fagerström
test for Nicotine Dependence (FTND)
Assess a client’s nicotine withdrawal symptoms
Pragmatically assess a client’s psychological state (e.g. depressed mood) insofar as it is
relevant to the quit attempt
3.8 Planning behavioural support;
 Assist the client to set a quit date
 Use relevant information from a client to tailor behavioural support
 Show an appreciation of client choice, and emphasise a client’s choice and preferences
within the bounds of evidence-based practice
3.9 Delivery of behavioural support;
Directly addressing motivation in relation to smoking and smoking cessation
 Provide the client with accurate information on the consequences of smoking and
smoking cessation in a way that maximises motivation to quit or stay quit
 Describe to the client the principles and effectiveness of typical behavioural support and
pharmacological therapies that can support a quit attempt
 Apply appropriate behavioural support strategies to enhance a client’s motivation and
self-efficacy
 Maximise the client’s commitment by prompting the client there and then to affirm a
strong commitment to start, continue, or restart the quit attempt
 Assist the client in identifying his/her reasons for wanting to stop smoking and address
concerns that they may have about the possible negative aspects of stopping
 Emphasise to the client the importance of, and secure commitment to, the ‘not a puff’
rule once the quit date has been reached
 Deal appropriately with ‘lapses’ to minimise the likelihood that they will lead to full
‘relapse’
 Provide feedback on a client’s performance and progress towards becoming a
permanent non-smoker, including praise contingent on successfully remaining abstinent
 Help to strengthen the client’s ‘ex-smoker’ identity (e.g. encouraging the smoker to
regard smoking as no longer part of his or her life)
Maximising capacity and skills for exercising self-control;
 Accurately describe to the client what they may experience in terms of nicotine
withdrawal symptoms and suggest evidence-based approaches to alleviate these
 Discuss barriers, triggers, and relapse predictors and assist the client in developing
appropriate strategies to cope with them
 Assist the client in setting achievable goals (e.g. one day at a time) that support the aim
of remaining abstinent, and prompt frequent review of progress towards the goal of
being permanently smoke-free
 Use expired air CO measurement as a motivational tool to assess the extent of a client’s
smoke exposure prior to quitting and to confirm successful abstinence
 Advise on the restructuring of the client’s social life, including specific advice on avoiding
exposure to social cues for smoking
 Discuss potential ways of changing the client’s daily routines and physical environment
in order to minimise exposure to smoking cues (e.g. removing ashtrays)
 Suggest ways of minimising stress and other psychological demands so as to conserve
mental resources
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
For concerned clients, outline weight and alcohol/caffeine consumption control
methods
Promoting effective medication use and other supporting activities;
 Describe to clients the full range of pharmacological therapies available and how they
work; and assist clients in choosing which pharmacological therapy is best suited to their
needs,
 Giving practical information and/or demonstrations on their use and monitoring the
continued suitability of the chosen product
 Assess the client’s experience of any stop smoking medications s/he is using, including
enquiries into their usage, side effects and experienced benefits
 Advise clients appropriately on adjusting medication usage in the light of their
experiences
 Enact the necessary local procedures to ensure the client receives his/her medication
easily
 Facilitate and advise on the client’s use of social support from friends, relatives,
colleagues, or ‘buddies’
 Provide options for obtaining additional and later support (including telephone and
online support) where these are available
General communication;
 Build rapport with clients
 Communicate in an empathic and non-judgmental manner, using reflective listening and
providing reassurance throughout
 Elicit the client’s views and questions on smoking, smoking cessation, and any aspect of
behavioural support, answering questions in a clear and accurate manner
 Describe to the client the expectations regarding the treatment programme, including
its typical length and content, plus what it requires of the client
 Explain the reasons for measuring CO both prior to and after the quit date
 Distinguish between appropriate and inappropriate written materials, and should they
be required, offer/direct the client to appropriate materials in ways that promote their
effective use
 Provide clients with summaries of the information they have received and prompt
confirmation from the clients regarding any decisions or commitments they have made
Professional practice;
 Keep accurate records for personal use of the numbers of clients seen, and Russell
Standard (clinical) success rates
 Accurately record information necessary for local and national monitoring
 Regularly reflect on own practice and assess possible areas for improvement
 Undertake the duties of a Stop Smoking Specialist in a way that meets the appropriate
ethical standards
 Obtain and accurately interpret important new information that relates to their clinical
practice
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3.9.1 Group-based behavioural support;
 Learning resources and training course content should result in Stop Smoking Specialists
being able to do the following:
Planning behavioural support in (closed) group contexts;
 Assess a client’s suitability for group support
 Plan, organise, establish and run a stop smoking group
 Manage problems of co morbidity (psychological and physical) within the group
appropriately
Maximising motivation to quit within the (closed) group context;
 Stimulate and facilitate supportive group discussions
 Apply techniques, such as group tasks or placing of chairs, to reinforce group interaction
and enhance mutual group support and/or bonding
 Encourage clients to make public promises/contracts with other group members
 Foster a sense of responsibility to the group
 Encourage group members to compare their CO readings
 Facilitate communication of group member identities (e.g. using name badges,
encouraging client’s to talk about themselves)
 Report on missing members appropriately so as to maintain group motivation
Supporting activities in the (closed) group context;
 Facilitate choice of medications in a group context
 Encourage sharing of experiences of medication use
Communication in the (closed) group context;
 Describe the content of group support sessions and ways in which group processes can
sustain or enhance motivation to stop smoking, and to help create accurate positive
treatment expectations
N.B. Recommendation - Mental Health 4
Given the prevalence of mental health issues in the prison setting, (Bradley, 2009) it is
recommended that staff operating at this level complete the NCSCT Mental Health specialty
module.
STRUCTURE / MODEL FOR DELIVERY
Training Delivery
The core training will be delivered by the community stop smoking services with specific input in
relation to the delivery of services in the prison setting and or where prison health care delivers the
Stop Smoking Service by trained leads in the prison service. These are likely to be the prison based
leads responsible for the delivery of stop smoking services.
4
Additional speciality training recommended by the NCSCT (NCSCT, 2010)
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Training the Trainers
The training would be designed to be delivered on a cascade training basis. Key staff in each
establishment would be trained up to Specialist Advisor level 3 by the Community stop smoking
teams, who will then act as a central resource to cascade training across the prison. All staff could
then be trained in phases to be equipped with as a minimum level 1.
Community Stop Smoking Teams
The role of the Community Stop Smoking Teams will be to provide the expertise to design and
deliver training in line with this guidance and tiered approach and act as an on-going support to
maintain and develop competency and capacity. This largely reflects the current position in many of
the North West prisons. By training and skilling up staff in the prison system workforce capacity is
increased, relieving pressure on already over stretched health care and community services. The
community teams would also be freed up to provide a level of performance monitoring and support
service development to individual establishments.
Alternative and Diversionary Activities – Prisons
A core element of the training will focus on exploring alternative and diversionary activities. In many
instances training has been tailored to reflect the needs of prisoners and the prison context as many
of the activities advocated for smokers trying to quit in the community aren’t applicable for the
prison setting. Currently many North West prisons offer access to additional gym sessions as a way
of supporting individuals5. Consideration needs to be given within the training as to what
alternatives are feasible in each establishment. Examples are highlighted these may include:-
5
Drawn from the project mapping activity
16
Table 5: Alternative and Diversionary Activities

Cell based physical activity routines for example, ‘pumping pad’

Yoga and Relaxation including meditation tapes and exercises

Music

Diversions from smoking; study, read , games, mints fruit water

Structured programmes for the day for example….

Sleep hygiene programmes; techniques to support sleep

Written activities; puzzles , diary keeping, creative writing and drawing

Access to additional dental services that include cleaning and polishing

Beauty and body care treatments such as …..
Assessing and Maintaining Competency
T able 4 outlines a summary of the key knowledge and skills at each of the 4 levels of training. It
provides a checklist of the core learning outcomes for the delivery of training at each level. This is
developed on a cumulative knowledge basis i.e. each level builds on the previous level.
Depending on the level of training staff will need a variety of on-going support to be able to maintain
their knowledge and skills base.
Level 1 and 2
Staff working at level 1 and 2 would be supported by the Community Stop smoking teams or their
lead/champion in each establishment.
Level 2B and Level 3
Staff operating at level 3 and potentially 2B will be supported to develop their competency by being’
shadowed’ in both the prison and community setting as is the case across a number of local
community services. Staff operating at this level would be expected to have successfully completed
the online accreditation with the NCSCT.
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LEARNING OUTCOMES CHECKLIST
Tiered approach - Learning outcomes checklist
Level
Competence
Knowledge
Skill
Level 1





Awareness of the key determinants of health
Explore smoking as a worked example – outlining the
key impact on health
Awareness of prison context

Awareness
Raising
Be able to identify routes to signpost
individuals to on-going advice and support
Be able to identify key risk factors in relation to
health, alcohol, physical activity and healthy
weight, smoking, mental health and well-being
Level 2A



Assessment and recording of smoking status
Assessment of readiness to quit
Referral to local services





The health risks of smoking and benefits of quitting
Reasons why stopping smoking can be difficult
Treatments to help with stopping smoking
Understand key issues in relation to smokers in prison
Wider context


Assessment
Treatment programme monitoring and
continuing education







Assessment
Delivering behavioural support
Group-based behavioural support





Brief
Intervention
Level 2B
Support and
Advice
Level 3
Specialist
Advisor



Understand key determinants of health in
relation to offender population
Describe main health benefits of cessation
Describe harmful effects of passive smoking
Provision Of VBA
Smoking demographics
The effects of smoking and stopping smoking
Smoking cessation treatments and their outcomes
Pharmacotherapy

Behavioural support
Smoking in the population
Smoking and health
Why stopping can be difficult
Smoking cessation treatments
The wider context

Planning behavioural support
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REFERENCES
Brooker C, Fox C, Barrett P & Syson-Nibbs L (2009). A Health Needs Assessment of Offenders on
Probation Caseloads in Nottinghamshire & Derbyshire: Report of a Pilot Study. Lincoln: CCAWI
University of Lincoln.
Bradley (2009). The Bradley Report: Lord Bradley’s review of people with mental health problems or
learning disabilities in the criminal justice system. London: Department of Health.
Department of Health (2002). Health Promoting Prisons: A Shared Approach. London: Department of
Health.
Department of Health (2003). Acquitted: Best Practice guidance for developing smoking cessation
services in prisons. London: Department of Health.
Dooris M (2006). Healthy settings: challenges to generating evidence of effectiveness. Health
Promotion International, 21(1): 55-65.
Health Development Agency (2003). Standards for training in Smoking Cessation treatments.
London: Health Development Agency.
Health Development Agency (2005). Skills and Competencies framework for trainers of smoking
cessation treatments. London: Health Development Agency.
National Institute for Health and Clinical Excellence (2008). Smoking cessation services in primary
care, pharmacies, Local Authorities and workplaces, particularly for manual working groups,
pregnant women and hard to reach communities. London: National Institute for Health and Clinical
Excellence.
NHS Centre for Smoking Cessation and Training (2010). Learning Outcomes for Training Stop
Smoking Specialists. London: NHS Centre for Smoking Cessation and Training.
Payne-James JJ, Green PG, Green N, McLachlan GMC, Munro MHWM & Moore TCB (2010).
Healthcare issues of detainees in police custody in London, UK. Journal of Forensic and Legal
Medicine, 17(1): 11-17.
World Health Organization (1986). Ottawa Charter for Health Promotion. Geneva: WHO.
World Health Organization (1980). Health for All. Geneva: WHO.
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USEFUL LINKS
www.uclan.ac.uk/hsdu
www.ukctcs.org
Healthy Settings Development Unit, University
of Central Lancashire
UK Centre for Tobacco Control Studies
www.ctcr.stir.ac.uk
Centre for Tobacco
University of Stirling
www.ncsct.co.uk
NHS Centre for Smoking Cessation and Training
Control
Research,
www.ash.org.uk
www.tobaccofreefutures.org
ASH Action on Smoking and Health
Tobacco Free Futures
www.nosmokingday.org.uk
(Formerly Smoke Free North West)
No Smoking Day 2011
www.roycastle.org
The Roy Castle Lung Cancer Foundation
CONTACT DETAILS
Stephen Woods
North West Tobacco Control Co-ordinator, Prisons & Criminal Justice Settings Demonstration
Project, UCLan
smwoods2@uclan.ac.uk
01772 893651
07891 614692
Michelle Baybutt
Intervention Manager UCLan
mbaybutt@uclan.ac.uk
01772 8933764
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