01Role and principlesWho benefits and the main preventive aims.
Lifestyle measures reduce cardiovascular risk across the life course and remain essential when medicines are prescribed. Avoid moralising: identify what the person values and turn it into one achievable, measurable change.
Tobacco dependence is relapsing and treatable. NICE supports behavioural support plus medicinal options including varenicline, combination short- and long-acting NRT, single-form NRT, bupropion and cytisinicline when appropriate.
Key points
- Ask and record current tobacco and nicotine use at every relevant encounter; offer treatment rather than advice alone.
- Combine behavioural support with an effective stop-smoking medicine when acceptable and suitable.
- Adults should aim for at least 150 minutes of moderate or 75 minutes of vigorous activity weekly plus strength work on at least 2 days.
- Use a cardioprotective eating pattern rich in vegetables, fruit, wholegrains, pulses, nuts and fish, replacing saturated with unsaturated fat.
- Adults should consume no more than 6 g salt daily.
- If alcohol is consumed, advise no more than 14 units weekly, spread over 3 or more days, with drink-free days.
- Set a specific goal, anticipate barriers and arrange follow-up; a generic instruction to live more healthily is not an intervention.
02Assessment and patient selectionRisk features, eligibility and important cautions.
Smoking soon after waking, withdrawal symptoms, high daily consumption or repeated relapse suggests stronger dependence and a need for adequate pharmacotherapy.
Exertional syncope, chest pain, disproportionate breathlessness or sustained palpitations requires cardiovascular assessment before vigorous exercise.
Binge pattern, loss of control, withdrawal, liver disease, hypertension or AF should trigger a fuller alcohol assessment rather than simple unit advice.
Recommendations must be feasible and should prompt appropriate support rather than restrictive advice.
Ask what change matters now, confidence on a 0-to-10 scale and what would move confidence one point.
03Baseline assessmentMeasurements that guide the plan and track progress.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Smoking and nicotine historyFirst step - Why
- Define products, daily use, dependence, previous attempts and triggers.
- Interpretation and limitations
- Include cigarettes, roll-ups, shisha, vaping and smokeless tobacco; carbon monoxide testing can support but does not replace history.
- 02
BMI and waist context - Why
- Identify weight-related risk and track change.
- Interpretation and limitations
- Interpret BMI with ethnicity, muscle mass, comorbidity and the person's goals; avoid making weight the only outcome.
- 03
Blood pressure, lipids and HbA1c - Why
- Quantify modifiable cardiovascular risk and detect hypertension, dyslipidaemia or diabetes.
- Interpretation and limitations
- Use the relevant NICE diagnostic and prevention pathways.
- 04
Alcohol units and AUDIT-C - Why
- Identify risky consumption and dependence.
- Interpretation and limitations
- A positive screen needs fuller assessment; suspected dependence requires planned support because abrupt unsupervised cessation may be unsafe.
- 05
Activity baseline - Why
- Measure weekly aerobic, strength and sedentary time.
- Interpretation and limitations
- Progress from the current level; some activity is better than none, but symptoms may require prior assessment.
04InterventionsLifestyle, treatment and escalation options.
01FirstBrief cardiovascular lifestyle interventionFirst stepRoutine prevention, chronic disease review or a teachable clinical moment.+
- 1Ask permission and assess smoking, diet, activity, alcohol, sleep, weight context and cardiovascular symptoms.
- 2Agree one personally meaningful SMART goal and specify how it will be measured.
- 3Offer the relevant NHS service or structured programme and remove practical barriers where possible.
- 4Record the plan and arrange review of progress and clinical risk factors.
02NextSupported quit attemptA person who smokes is willing to stop or reduce harm while moving toward stopping.+
- 1Agree a quit date or reduction plan and identify triggers, household support and previous effective strategies.
- 2Offer behavioural support plus a suitable medicine; explain correct use before the quit date.
- 3Review within the early quit period for withdrawal, adverse effects, lapses and dose adequacy.
- 4Continue support through the treatment course and treat a lapse as information, not failure.
03EscalationComplex dependence or clinical riskEscalationPregnancy, severe mental illness, alcohol dependence, repeated relapse, unstable CVD or exercise red flags.+
- 1Prioritise urgent diagnostic assessment for exertional cardiac symptoms or acute instability.
- 2Refer tobacco dependence to an NHS stop-smoking service and coordinate with mental-health, maternity or addiction care as relevant.
- 3In pregnancy or breastfeeding, prioritise behavioural support and consider NRT with pregnancy-specific counselling; do not offer cytisinicline, varenicline or bupropion.
- 4For suspected alcohol dependence, arrange a medically safe reduction or withdrawal plan rather than abrupt unsupported cessation.
05Medicines and treatment safetyRegimens, contraindications and review points.
Varenicline
Days 1 to 3: 0.5 mg orally once daily; days 4 to 7: 0.5 mg twice daily; from day 8: 1 mg twice daily, usually for 12 weeks.Reduce dose in severe renal impairment; nausea and vivid dreams are common. Review new or worsening neuropsychiatric symptoms. Not recommended in pregnancy or breastfeeding.
Combination nicotine replacement therapy
Typical high-dependence regimen: 25 mg/16-hour nicotine patch once daily plus 2 mg gum or lozenge when cravings occur, within the selected product's maximum dose.Match starting strength to dependence and product instructions; nausea, palpitations or dizziness may indicate excess nicotine. NRT is safer than continued smoking, including when considered in pregnancy with specialist support.
06Targets, monitoring and follow-upResponse, safety and longer-term review.
- At each cessation review record smoking status, lapses, withdrawal, cravings, medicine use and adverse effects.
- Recheck blood pressure, weight context, lipids and glycaemic measures according to the person's cardiovascular pathway.
- Track minutes of aerobic activity, strength sessions and sedentary breaks rather than relying on intention alone.
- Review alcohol units and pattern, especially when AF, hypertension, liver disease or mental-health symptoms change.
- Revisit goals after illness, relapse or social change and preserve successful elements of the prior plan.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Medication plus support
Correct technique, adequate dose and behavioural follow-up are part of the treatment, not optional extras.
Exercise dose can be accumulated
The weekly aerobic target can be built from shorter bouts, while prolonged sitting should also be interrupted.
Salt includes processed food
Most intake is not added at the table; label reading and food substitution make the 6 g target actionable.
Alcohol advice is a ceiling
Fourteen units is a low-risk limit, not a target; there is no completely safe drinking level.
Relapse is common
Review the trigger, restart support promptly and avoid framing a lapse as loss of all progress.
08Common pitfallsFrequent interpretation and management errors.
- 01
Giving vague lifestyle advice with no agreed goal or follow-up.
- 02
Under-dosing NRT in a highly dependent smoker and mistaking withdrawal for treatment failure.
- 03
Prescribing varenicline in pregnancy.
- 04
Recommending vigorous exercise before assessing exertional syncope or chest pain.
- 05
Calling 14 alcohol units per week safe or encouraging a non-drinker to start drinking.