This letter authorises the extended use of the following protocol until 1st September 2018:

Transcription

1 NHS Grampian Westholme Woodend Hospital Queens Road ABERDEEN AB15 6LS NHS Grampian Date: 22nd March 2018 Our Ref: FA/NRTComm/MGPG/Mar18 Enquiries to: Frances Adamson Extension: Direct Line: f.adamsonnhs.net Dear Colleague This letter authorises the extended use of the following protocol until 1st September 2018: NHS Grampian Protocol For The Provision Of Nicotine Replacement Therapy (NRT) For Patients With Nicotine Withdrawal Symptoms In Community Hospital By Registered Nurses The review of this protocol is currently underway and a new Patient Group Direction will be developed to replace this protocol and will be available later in If you have any queries regarding this please do not hesitate to contact the Pharmacy and Medicines Directorate. Yours sincerely C-17. Sandy Thomson Interim Chair of the Medicines Guidelines and Policies Group

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3 This document is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on (01224) or (01224) This controlled document shall not be copied in part or whole without the express permission of the author or the author s representative. Title: Unique Identifier: Replaces: Lead Author/Co-ordinator: Subject (as per document registration categories): Key word(s): Process Document: Policy, Protocol, Procedure or Guideline Document application: Purpose/description: Group/Individual responsible for this document: Policy statement: NHS Grampian Protocol For The Provision Of Nicotine Replacement Therapy (NRT) For Patients With Nicotine Withdrawal Symptoms In Community Hospital By Registered Nurses NHSG/Prot/NRT_InPat/MGPG726 NHSG/Prot/NRT_InPat/MGPG653 Elaine Neil Pharmacist Aberdeenshire CHP/ George Rutten Aberdeenshire Tobacco Lead Protocol Nicotine replacement therapy, NRT, nicotine withdrawal symptoms, smoking cessation, community hospital, minor injuries Protocol NHS Grampian This protocol details how to provide Nicotine Replacement Therapy (NRT) to Community Hospital in-patients who are smokers that cannot smoke while in hospital Head of Health Improvement, NHS Grampian It is the responsibility of all staff to ensure that they are working to the most up to date and relevant policies, protocols procedures. UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG726 - i -

4 Responsibilities for ensuring registration of this document on the NHS Grampian Information/ Document Silo: Lead Author/Co-ordinator: Lead Pharmacist, Aberdeenshire CHP Physical location of the Lead Pharmacy, Aberdeenshire CHP original of this document: Job title of creator of this Lead Pharmacist Aberdeenshire CHP document: Job/group title of those who Lead Pharmacist, Aberdeenshire CHP have control over this document: Responsibilities for disseminating document as per distribution list: Lead Author/Co-ordinator: Elaine Neil, Pharmacist Aberdeenshire CHP/George Rutten, Tobacco Lead Aberdeenshire Responsibilities for implementation: Organisational:CHP CHP General Manager Operational Management Units CHP Area Manger Directorate Level CHP Clinical Leads Sector Community Hospital Medical Directors, Community Hospital Mangers Departmental: Clinical Leads Area: Charge Nurse Review frequency and date of next review: This policy will be reviewed at least every two years or sooner if current treatment recommendations change. Responsibilities for review of this document: Lead Author/Co-ordinator: Pharmacist Aberdeenshire CHP/Tobacco Lead Aberdeenshire Revision History: Revision Date February 2015 February 2015 Previous Revision Date April 2014 April 2014 Summary of Changes (Descriptive summary of the changes made) Title amended to refer to all community hospital patients. Protocol now to include minor injury unit patients. Changes Marked* (Identify page numbers and section heading ) Throughout document Throughout document * Changes marked should detail the section(s) of the document that have been amended, i.e. page number and section heading. UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG726 - ii -

5 NHS Grampian Protocol For The Provision Of Nicotine Replacement Therapy (NRT) For Patients With Nicotine Withdrawal Symptoms In Community Hospital By Registered Nurses Contents Page No 1. Introduction Informed Consent Patient Assessment Carried Out By A Trained Nurse Who Has Undergone Smoking Cessation Training Contra-indications, Precautions And Further Information Product Choice Recording, Provision And Administration Of NRT Products Ongoing Monitoring while an In-patient Discharge From Hospital References And Further Information Available From Consultation Group... 9 Appendix Appendix Appendix 3 Pathway To Support Patients With Nicotine Withdrawal Symptoms In Community Hospital Appendix 4 - Hospital In-Patient Smoking Cessation Clinical Pathway UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

6 NHS Grampian Protocol For The Provision Of Nicotine Replacement Therapy (NRT) For Patients With Nicotine Withdrawal Symptoms In Community Hospital By Registered Nurses 1. Introduction Community Hospitals in Grampian will be smoke free by March 2015; smoking is not permitted inside the building or in the grounds. This protocol details how to provide Nicotine Replacement Therapy (NRT) to in-patients who are smokers who cannot smoke while in hospital. Smokers who cannot smoke may have withdrawal symptoms which could result in restlessness, irritability, nervousness, headaches and cigarette craving. In terms of this protocol in-patients are defined as patients staying in hospital or individuals being assessed within Minor Injury Units aged 16 years of age and over. All patients admitted as an in-patient will be asked smoking status on admission following the Pathway To Support Patients With Nicotine Withdrawal Symptoms In Community Hospital (Appendix 3). This will allow staff to: Identify nicotine dependent patients. Provide patients with information about smoke free hospital and grounds. Offer patients who smoke support for symptoms of nicotine withdrawal in the form of NRT whether they plan to stop smoking or not. Advise patients at discharge on options for smoking cessation. GP must be informed that a patient is getting NRT so they can monitor the patient appropriately. Minor Injury Unit patients who request to smoke while being treated in the unit should be assessed using the Hospital In-Patient Smoking Cessation Clinical Pathway (Appendix 4). N. B. Electronic cigarettes are not recommended by NHS Grampian as part of an attempt to stop smoking as the current evidence on e-cigarettes remains weak and inconclusive and there is a lack of safety testing. 2. Informed Consent The patient s informed consent must be obtained before NRT can be provided; preferably written, either from the patient, parent, guardian or person with parental responsibility and documented either in the patient s medical records/notes or on an administration form. Consent must be in line with current NHSG Staff Policy for Obtaining Consent for Clinical Procedures and Healthcare Interventions. See link UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

7 3. Patient Assessment Carried Out By A Trained Nurse Who Has Undergone Smoking Cessation Training In order to decide on the level of NRT support required nursing staff must identify the level of nicotine dependence using the Hospital In-Patient Smoking Cessation Clinical Pathway algorithm (Appendix 3), which includes the Fagerstrom test. 1. When was your last cigarette? Record date. 2. How soon after waking do you smoke your first cigarette? Record score Over 60 mins (0) mins (1) 5-30 mins (2) within 5 mins (3) 3. How many cigarettes a day do you smoke? Record score 10 or less (0) (1) (2) 31+ (3) 4. Are you currently using NRT? Record answer Yes (record NRT) No (Continue pathway). 5. Does the patient want to stop smoking long term? Yes (refer to SAS and continue pathway) No (Continue pathway). Score: 1-2 = low dependence patient may not need NRT and is monitored for withdrawal symptoms. 3-4 = moderate dependence please check NRT recommendations Table = high dependence consider combination therapy, please check NRT recommendations in Table 1. Patients who are nicotine dependent should be offered NRT for symptomatic relief. In order to support patients who want to stop smoking on discharge they will be given a minimum of 7 days supply of NRT via a GP10 prescription and advised on the arrangements for future support. 4. Contra-indications, Precautions And Further Information Contra-indications Hypersensitivity to nicotine or any ingredient of the preparation being considered. A patient hospitalised for MI, severe dysrhythmia or CVA/head injury who is considered to be haemodynamically unstable should be encouraged to stop smoking with non-pharmacological interventions unless initiated by a doctor. These patients should be discussed with Smoking Advice Service who may then discuss with a GP if a prescription is being requested. UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

8 Precautions Stopping smoking can affect the metabolism of certain medicines resulting in an increase in the blood levels of the medicine. Particular care is required for patients taking: o o o Warfarin Some anti-psychotics, e.g. clozapine, olanzapine Theophylline Skin disorders caution with patches Phenylketonuria caution with lozenges Gastrointestinal Disease caution with oral nicotine products Moderate or severe renal or hepatic impairment Phaeochromocytoma Uncontrolled hyperthyroidism Diabetes monitor blood sugar closely Pregnancy and lactation use short acting products. 5. Product Choice Discuss options with the patient. The choice of nicotine replacement preparations depends largely on patient preference and should take into account what preparations, if any, have been tried before and also on whether or not the patient is aiming to quit smoking completely. Nurses trained in smoking cessation may offer products in Table 1. Refer to current BNF for information on products available, their advantages/disadvantages and the relevant reducing dose titrations. If a medicine is not included in Table 1 it must be prescribed by an authorised prescriber before being administered to the patient. For Minor Injury Unit patients who smoke Every minutes administer one form of short acting NRT products to help with cravings. Use appropriate NRT product based on Fagersrtom Test. Advise on correct administration and do not exceed recommended dosage. Consider applying NRT patch if patient is likely to be admitted to hospital. For patients who will not smoke during their admission (i.e. will not go off-site to smoke) Nicotine patches are a prolonged release formulation and are applied for 16 hours (with the patch removed overnight) or for 24 hours. If the patient experiences strong cravings for cigarettes on waking, a 24 hour patch may be more suitable. Immediate release nicotine preparations (gum, lozenges, inhalator) are used whenever the urge to smoke occurs. Patients with a high level of nicotine dependence, or who have failed with nicotine replacement therapy previously may benefit from using a combination of a long acting preparation and an immediate release short acting preparation to achieve abstinence. UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

9 For patients who are going to continue to smoke by going off-site during admission These patients should be informed of the risks involved when leaving the grounds and provided with short acting NRT, e.g. gum or lozenges or an inhalator to help with managing cravings. This should be provided at the appropriate strength on an as required basis for possible nicotine withdrawal effects due to a reduction in the amount of cigarettes smoked or if the patient craves a cigarette but is unable to smoke. For patients (16 years and older) staying in the hospital long-term who are using NRT while an in-patient or for patients who wish to stop smoking while in hospital Refer to the smoking advice service (freephone: ) advising that this is a hospital in-patient, to ensure that people receive the appropriate support and assistance with NRT management or stopping smoking. For patients (15 years and under) staying in the hospital or in the Minor Injury Unit Younger people with a high level of nicotine dependence should be discussed with the GP if NRT is being requested. UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

10 Table 1 Only NRT detailed in the table below can be supplied by nurses trained in smoking cessation. Refer to BNF for detailed information on the complete range of NRT products available. If a medicine is required that is not detailed in Table 1 it must be prescribed on the Prescribing and Administration Record by an authorised prescriber before being administered to the patient. Long- Acting NRT Short- Acting NRT Short- Acting NRT Smoking Rate Moderate and high dependency NRT Low Dependency NRT > 20 Cigarettes/day Cigarettes/day <10 Cigarettes/day NICOTINE PATCH (Nicorette 16hr, Niquitin 24hr) Nicorette Nicorette Nicorette Invisi Patch Invisi Patch Invisi Patch (16 hour patch) (16 hour patch) (16 hour patch) 25mg patch 25mg patch 15mg patch NiQuitin Patch (24 hour patch) 21mg patch NICOTINE GUM or LOZENGE 4mg gum/lozenge Used as required, max 15/day. NiQuitin Patch (24 hour patch) 21mg patch 2mg gum/lozenge Used as required, max 15/day. NiQuitin Patch (24 hour patch) 14mg patch 2mg gum/lozenge Used as required, max 15/day. NICOTINE INHALATOR (Nicorette ) 15mg cartridges Used as required. A single 15mg cartridge lasts for approximately 40 minutes of intense use. Note: Not suitable for heavy smokers unless used in combination. Patients with obstructive respiratory disease may find it difficult to use. NICOTINE ORAL SPRAY (Nicorette Quickmist mouthspray) Use1-2 sprays in the mouth when the urge to smoke occurs or to prevent cravings Do not exceed 2 sprays per episode (up to 4 sprays every hour) Maximum of 64 sprays daily. Administration Apply one daily each morning. Remove 16 hour patch before bed. Remove 24 hour patch next morning. Apply fresh patch to alternative site. Gum: Chew the gum until the taste becomes strong, then rest it between the cheek and gum. When the taste starts to fade repeat this process. Patients with dentures may experience difficulty in chewing nicotine gum. The gum may stick to, and may in rare cases damage dentures. Lozenge: Slowly allow each lozenge to dissolve in the mouth; periodically move the lozenge from one side of the mouth to the other. Lozenges last for approximately minutes, depending on their size. Patients should not exceed 6 cartridges of the 15mg strength daily. Follow administration advice in the pack. Release one spray into the mouth, avoiding the lips. Do not inhale while spraying. Do not swallow for a few seconds after spraying. UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

11 Combination Therapy Patients with a high level of nicotine dependence, or who have failed with nicotine replacement therapy previously may benefit from using a combination of a patch and an immediate release short acting preparation to achieve abstinence. Use a lower strength (2mg) lozenge or gum as required. 6. Recording, Provision And Administration Of NRT Products NRT products can be bought over the counter (OTC) by members of the public. In-patients - all medicines including OTC products must be recorded on the Prescribing and Administration Record as the use of these and the fact that the patient has stopped smoking can affect other medicines. Information must be completed as detailed in the Instructions for NHS Grampian Staff on the In-Patient Prescribing and Administration of Medicines using the NHS Grampian Prescription and Administration Record. UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

12 Minor Injury Unit Patients all medicines supplied or administered must be recorded on ADASTRA or on the NHS Grampian Casualty Unit sheet. Nurses who have attended appropriate smoking cessation training may assess any patient who wants NRT support and agree which products will be used. Products used can only be those listed in this protocol. If a patient requests other products they should be referred to the smoking cessation service. Ward nurse must make an entry in the Patients Prescribing and Administration Record of all products being used. Check the allergy section for any known adverse effects to NRT products. NRT patches should be written in the Regular Therapy section. Administration should be recorded in the usual way. Short acting NRT products should be written in the As required section. The product and quantity that will be supplied to the patients should be recorded. The Prescriber signature box must be signed by the nurse carrying out the assessment and agreeing with the patient the products to be used. NRT Protocol must be entered in the Additional Instructions box. Minor Injury Unit nurse to make an entry on ADASTRA or in the NHS Grampian Casualty Unit sheet in accordance with local guidance. Check the allergy section for any known adverse effects to NRT products. Nurses to make a paper referral to smoking cessation services for those patients motivated to quit smoking and requesting additional support through either the smoking cessation service OR the pharmacy smoking cessation service. If no smoking cessation trained nurses are on duty a doctor should be asked to prescribe NRT. 7. Ongoing Monitoring while an In-patient Monitor for changes in the use of NRT products and smoking status. GP must assess the potential effect on other medicines medical/ conditions. 8. Discharge From Hospital On discharge Ward in-patients discharged and triaged as motivated to stop smoking will be: Referred to either : o The Smoking Advice Services (SAS), using a telephone referral (Tel: ), including the comment referred from a community hospital. Or o Their local Community Pharmacy. Advised on the option to continue smoking cessation, using the pharmacy smoking cessation services or the Smoking Advice Services. Offered a 7 day supply of NRT (via a GP10 prescription) to help to deal with the urge for tobacco products. UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

13 Informed that the SAS may ask questions about the patient s smoking status. Patients who want to stop smoking on discharge should be given a minimum of a 7 days supply of NRT via a GP10 prescription and advised on future support. 9. References And Further Information Available From Summary of Product Characteristics and Patient Information Leaflets, Nicorette and Niquitin, Electronic Medicines Compendium, NHS Grampian Joint Formulary NHS Grampian Guidance on Smoking Cessation and Psychotropic Drug Interactions. BNF Number 67 March Consultation Group Louise Black Gladys Buchan Wendy Grant Dr P. Guthrie Wendy Innocent Denise Kazmierczak Derek Petrie George Rutten Lead Pharmacist, Aberdeenshire CHP Operational Lead Nurse, Aberdeenshire CHP Charge Nurse, Turriff Medical Practice GP, Turriff Medical Practice Smoking Advise Services Tobacco Training and Development Co-ordinator Tobacco Control Advanced Public Health Coordinator UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

14 Appendix 1 Health Care Professional Agreement For The Provision Of Medicines In Accordance With NHS Grampian Protocol I: (Insert name) Working within: e.g. CHP, Practice Agree to administer medicines under the direction contained within the following protocol NHS Grampian Protocol For The Provision Of Nicotine Replacement Therapy (NRT) For Patients With Nicotine Withdrawal Symptoms In Community Hospital By Registered Nurses I have completed the appropriate training to my professional standards enabling me to administer/supply medicines under the above Protocol. I agree not to act beyond my professional competence nor outwith the recommendations of the Protocol. Signed: Print Name: Date: NMC Registration No: UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

15 Appendix 2 Certificate Of Authorisation For The Provision Of Medicines Under Protocol This authorises: Working within: e.g. CHP, Practice To administer/supply medicines under the following Protocol NHS Grampian Protocol For The Provision Of Nicotine Replacement Therapy (NRT) For Patients With Nicotine Withdrawal Symptoms In Community Hospital By Registered Nurses The above named person has satisfied the training requirements and is competent to administer/supply medicines under the above Protocol. The above named person has agreed not to act beyond their professional competence nor out with the recommendations of the Patient Group Direction Signed: Authorising Manager/Doctor Print Name: Date: UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

16 Appendix 3 Pathway To Support Patients With Nicotine Withdrawal Symptoms In Community Hospital This flowchart shows the pathway to follow in raising the subject of smoking with a patient admitted to a Hospital. Find out first if the patient is smoking as part of the Patient Admission Assessment Document. If the patient does smoke, find out if they are interested in stopping and then offer the best help available. Note: Smoking is not permitted inside the hospital building or hospital ground. Inform patients wishing to smoke of the risk of going off the hospital ground to smoke. Patient Assessment Document Ask: Do you smoke? Document response in 3.Breathing No Congratulate Continue questions Patient Assessment Document Yes Explain that the hospital is a smoke free hospital and that the patient may be referred to a smoking advice service. Explain that smoking is not permitted in the hospital premises or outside on the hospital ground. Explain the patient will be visited for smoking advice at a more appropriate time. Continue with the Patient Assessment Document questions Revisit the patient Explain that you come to offer help. Smoking is not permitted inside the hospital or on the hospital ground. Explain you can offer help to control cravings for tobacco. Continue Ask: Are you interested in trying to stop and, if so, do you feel motivated to stop now or in the near future? No Briefly outline the health risks of smoking and the benefits of stopping (can be related to the patient s condition). Yes Ask: Would you like help from the stop smoking services provided in the hospital? Yes Explain to the patient that you can provide products to increase the chances of stopping smoking and staying stopped. Explain the range of NRT products available Ask: Would you like to use NRT or other medication? No No Accept answer without judging. Explain that smoking is not permitted inside the hospital or hospital ground. Advise patient of risks of going off site to smoke Explain briefly that there is a range of services (smoking advice service/ pharmacist) and a range of products (long term NRT/ short term NRT) available to reduce the urge to smoke Confirm: Would you like to use NRT or other medication? No Give: Information on how to stop smoking and support available (e.g. leaflet) Remind patient smoking is not permitted in the hospital or on the hospital ground. Patient can ask for help anytime for support to control cravings for tobacco. Yes Yes Continue with the hospital in-patient smoking cessation clinical pathway; Assess (condensed Fragerstrom test): 1. When was your last cigarette? Record date. 2. How soon after waking do you smoke your first cigarette? Record score Over 60 mins (0) mins (1) 5-30 mins (2) within 5 mins (3) 3. How many cigarettes a day do you smoke? Record score 10 or less (0) (1) (2) 31+ (3) 4. Are you currently using NRT? Record answer Yes (record NRT) No (Continue pathway). 5. Does the patient want to stop smoking long term? Smoking Advice Service: Yes (refer to SAS and continue pathway) No (Continue pathway). Mention a referral from a hospital Total score 2+3: 1-2 = low tobacco dependence 3-4 = mod tobacco dependence 5+ = high tobacco dependence Continue with Hospital In-patient Smoking Cessation clinical pathway form UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

17 Appendix 4 - Hospital In-Patient Smoking Cessation Clinical Pathway To be used for patients admitted to a hospital and identified as a current smoker in the Patient Admission Assessment Document. Use in combination with Protocol for the Provision of NRT for Nicotine Withdrawal Symptoms in Community Hospital In-Patients Smoking Cessation Clinical Pathway CHI: Name: Address: DoB: (affix identification label here) Male / Female Ask Assess Date: 1. When was your last cigarette? Date: / / 2. How soon after waking do you smoke your first cigarette? Over 60 mins (0) mins (1) 5-30 mins (2) within 5 mins (3) 3. How many cigarettes a day do you smoke? Total score 2+3: 10 or less (0) (1) (2) 31+ (3) 1-2 = low tobacco dependence 3-4 = mod tobacco dependence 4. Are you currently using NRT? 5+ = high tobacco dependence Yes No Continue pathway. Initial Assist Treatment options For complete range refer to BNF For administration usage check Protocol for NRT Smoking Advice Service Ask: Are you nicotine dependent? Do you need NRT? Moderate and high dependency NRT Low dependency NRT No need NRT Products to choose from Long- Acting NRT Smoking Rate > <10 Cigarettes/day Cigarettes/day Cigarettes/day NICOTINE PATCH (Nicorette 16hr, Niquitin 24hr) Nicorette Patch Nicorette Patch Nicorette Patch (16 hour patch) (16 hour patch) (16 hour patch) 25mg patch 25mg patch 15mg patch NiQuitin Patch (24 hour patch) 21mg patch NiQuitin Patch (24 hour patch) 21mg patch NiQuitin Patch (24 hour patch) 14mg patch Behavioural support Continue next page for short acting NRT. UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG

18 Continued from previous page. Moderate and high dependency NRT Low dependency NRT No need NRT Products to choose from Short- Acting NRT Smoking Rate > Cigarettes/day Cigarettes/day NICOTINE GUM or LOZENGE 4mg gum/lozenge 2mg gum/lozenge Used as required, Used as required, max 15/day. max 15/day. <10 Cigarettes/day 2mg gum/lozenge Used as required, max 15/day. Behavioural support Short- Acting NRT NICOTINE INHALATOR (Nicorette ) 15mg cartridges Used as required. Patients should not exceed 6 cartridges of the 15mg strength daily. NICOTINE ORAL SPRAY (Nicorette Quickmist mouthspray) Use1-2 sprays in the mouth when the urge to smoke occurs or to prevent cravings Up to 4 sprays every hour. Maximum 64 sprays daily. Record product used in NHS Grampian Prescription and Administration Record Sheet and patient clinical notes Arrange follow up Hospital discharge date Have patient clinical notes been completed? Does the patient want to stop smoking long term? - Yes: Explain options; Smoking Advice Service or pharmacy Patient indicated wanting a referral to (please tick): Smoking Advice Service Call: Pharmacy Provide patients with mod/ high nicotine dependency with NRT for 7 days. Record product used. Completion date: - No: Remind the patient of the services that are available to stop smoking UNCONTROLLED WHEN PRINTED Review Date: March 2017 Identifier: NHSG/Prot/NRT_InPat/MGPG