Smoking cessation
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Free Smoking cessation

Wendy Preston Head of nursing practice, RCN, London, England

The health burden of smoking tobacco is well documented and it is known to kill more than half its users. Nurses have a pivotal role in promoting smoking cessation and this is going to be even more important in the current financial climate because of the economic burden placed on health and social care.

This article will discuss integrating brief intervention advice into clinical practice, and provide useful training resources that are available to upskill nurses and other healthcare professionals. It will explain smoking cessation treatment and outline the support required to help people successfully quit.

Primary Health Care. 27, 8,35-42. doi: 10.7748/phc.2017.e1283

Correspondence

wendy.preston@rcn.org.uk

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Conflict of interest

None declared

This article has been funded by Pfizer. Pfizer has had no editorial input to the content but has reviewed for technical accuracy

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Received: 22 February 2017

Accepted: 05 July 2017

Published in print: 27 September 2017

Aims and learning outcomes

This article aims to guide the reader in understanding the pivotal role primary care nurses have in helping patients to quit smoking.

After reading this article and completing the associated time out activities, you should be able to:

  • » Summarise how tobacco smoking increases the burden on people’s health.

  • » Discuss what is involved in providing brief intervention advice.

  • » Outline how you might integrate brief intervention advice into primary healthcare.

  • » Summarise the smoking cessation treatments available to patients.

Introduction

The recreational use of tobacco in England dates back to the 16th century. It is smoked to obtain the drug nicotine, principally to relieve symptoms of nicotine withdrawal. Nicotine is an agonist that releases dopamine, which produces the ‘feel-good’ effect. However, it has a short half-life so its effect does not last long before another dose is required. Tobacco contains more than 4,000 chemicals, many of which are carcinogenic, including tar, oxidant gases and carbon monoxide (Bernhard 2011). Lighting a cigarette creates temperatures ranging from 400ºC to 700ºC, and produces a wide range of chemicals derived from the tobacco, its paper and additives (Cope 2016).

When all of this is considered, the damage done to the body is unsurprising. It harms nearly every organ; drastically reduces quality of life and life-expectancies (Bernhard 2011); and causes much, often unseen, suffering through co-morbidities. Ultimately, tobacco kills more than 50% of smokers (Box 1).

Box 1

The effects of smoking on health and mortality

  • » 100,000 deaths per year in the UK.

  • » Leading cause of preventable death and disease.

  • » A total of 18% of all deaths in adults aged over 35 are attributed to smoking.

  • » Half of all smokers die as a result of smoking – with a reduced life expectancy of ten years on average.

  • » Smoking causes:

    • 36% of all respiratory deaths.

    • 28% of all cancer deaths.

    • 14% of all circulatory disease deaths.

Action on Smoking and Health (ASH) (2016)

Manufactured cigarettes - which most commonly now come with filters - have been more popular than hand-rolled cigarettes since the 1950s (Bernhard 2011). However, roll-up cigarettes are still common and are used disproportionately by poorer smokers, who are usually highly addicted (Cope 2016). Approximately 16% of the UK population smokes tobacco and it is much higher in certain groups (Smoking in England 2017). For example, 60-70% of people with severe mental health conditions smoke and their mortality rates are three to four times higher than those of the general population, depending on where in the UK they live. People from deprived backgrounds are also much more likely to smoke. The gap between smoking prevalence according to socio-economic background has widened in recent years: an unemployed person in England is twice as likely to smoke as someone in work, a retiree or a student (Health and Social Care Information Centre 2015) (Figure 1).

Figure 1

Deaths caused by smoking each year in England

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There are also second-hand effects for people in the presence of cigarette smoke. ‘Passive smoking’ is when the sidestream smoke from the tip of a cigarette and the exhaled smoke are inhaled by a third party (ASH 2014). Immediate effects include eye irritation, headaches, coughing, dizziness and nausea. Severe long-term effects include:

  • » Declined lung function in adults with asthma.

  • » New cases of asthma in children whose parents smoke.

  • » 1% of worldwide mortality.

The annual cost of smoking-related healthcare in the UK is estimated at £2 billion (ASH 2016). ASH (2017a) also showed the lesser known costs of social care caused by smoking tobacco, which increased from £1.1 billion in 2014 to £1.4 billion in 2016. When all aspects of smoking tobacco are taken into account, including loss of productivity, the total annual cost to the UK is estimated to be £13.8 billion (NHS 2015).

The effects of smoking are not isolated to humans. VN Futures (2016) highlighted the effects of smoking on animals, especially pets that live in a household with smokers. It also discussed an interesting concept: improving the health of a household (humans and animals), which will be discussed later in the article in relation to promoting smoking cessation.

Nurses’ role

Nurses are in a prime position to promote smoking cessation and its benefits (Table 1). Practice nurses and community teams not only care for patients with smoking-related diseases, but also have contact with the general public.

Table 1

The health benefits of giving up smoking

Time after giving upEffect
20 minutesReduction in blood pressure and pulse rate; normalisation of the temperature of the hands and feet
48 hoursSenses of smell and taste return
Two weeks to three monthsRisk of myocardial infarction (Ml) begins to fall and lungs begin to improve
Three weeks to three monthsDecrease in respiratory symptoms (coughing and breathlessness)
One yearExcess risk of Ml and stroke decreased to less than half that of the average smoker
Ten yearsRisk of death from lung cancer almost half that of the average smoker
15 yearsRisk of heart disease now the same as that of someone who has never smoked
Source: British Thoracic Society (2013)

The starting point to helping is a simple question: ‘Do you smoke?’ Smokers expect this question and not asking could give the impression that giving up smoking is not a priority. As 70% of smokers would like to give up (National Centre for Smoking Cessation and Training (NCSCT 2017), offering brief intervention advice should be less of a challenge.

Time out 1

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Behavioural change – RCN

www2.rcn.org.uk/development/practice/cpd_online_learning/support_behaviour_change

This resource discusses the support required to promote behavioural change. As you read it, consider how you build rapport during clinical practice to promote behavioural change.

Making every contact count (Public Health England (PHE) et al 2016) is an approach that uses the millions of contacts with patients that healthcare professionals and organisations have to support in making positive changes to their physical and mental health and well-being. It involves asking about lifestyle, giving brief advice and then referring the patient to a service or person for a more in-depth intervention. It is also referred to as ‘brief intervention advice’ and is summarised in Box 2.

Box 2

What nurses can do to help patients give up smoking

ASK – all patients if they smoke.

ADVISE – on the best way to stop.

ACT – provide a referral or offer behavioural support and drug treatment. For example, try the following approach: ‘The best way to quit is a combination of behavioural support and treatment. I would like to refer you. Is that okay?’

(NCSCT 2014)

Ask

Tobacco consumption is often under-reported, especially when patients discuss their habits with healthcare professionals (Cope 2016). However, people expect healthcare professionals to ask about their smoking history, especially when a medical history is being taken. It can be done without judgement. Not asking sends a negative message.

When taking a comprehensive smoking history, nurses should start with the age the patient began smoking then look at types of smoking and changes across their life. It is important to ask about different types of smoking, so nurses need to routinely ask questions such as:

  • » ‘Do you smoke?’

  • » ‘Have you ever smoked cannabis or other drugs?’

  • » ‘Do you ever use a shisha or a water pipe?’

If nurses integrate this questioning into health assessments regularly and consistently, it becomes natural and easy. Nurses need to adopt a non-judgemental attitude when asking patients about their smoking habits. Patients may have had a range of exposure, regardless of their age or background. Once nurses have acquired a patient’s smoking history, it is important to document it by recording ‘smoking pack years’. One smoking pack year is the equivalent of smoking 20 cigarettes a day for one year. Table 2 demonstrates smoking pack years for a range of tobaccos. Health professionals can also use the calculator at smokingpackyears.com to calculate smoking pack years across a range of types of smoking and changes at different stages of life (Box 3).

Table 2

Types of smoking in ‘packyears’

TypesAmountYearsPack years
Cigarettes (manufactured)20 per day2020
Cigar2 per day208
Cigarillo2 per day204
Roll-up100g per week2029
Pipe5 bowls per day2013
Shisha (water pipe)One 20-minute session, twice a week207
Cannabis spliff2 per day208
Source: smokingpackyears.com
Box 3

Case study – Mr A

Mr A is being reviewed for a chronic cough. He is 40 years old and has consistently smoked 20 manufactured cigarettes a day since he was 15. For ten years, he smoked an average of two cannabis joints per day. He then switched to shisha, using it three times per week for 20 minutes. His total smoking pack years is therefore 34, which is different to the 25 if only his cigarette smoking pack years had been taken into account.

It is also important to reinforce positive health messages for two other groups:

It important that nurses support patients who have recently given up smoking, as this increases their chances of quitting in the long-term. Positive reinforcement for ex-smokers is also important, as is checking their status. For example:

  • » ‘I notice you quit smoking last year - are you still doing well with this?’

  • » ‘That’s fantastic as it is the best thing you can do for your health.’

Advise

Patients look to healthcare professionals to provide advice about health and lifestyle. Doing so is important, as it ensures they can make an informed choice. Many nurses worry about what to say. However, it is reasonably straightforward and having a few sentences in the nurses’ ‘clinical tool box’ is useful:

  • » ‘The best way to stop smoking is with the combination of treatment and support that is available on the NHS – is that something that would interest you?’

  • » ‘With the right support and treatment, it can be much easier to stop and stay stopped. Could I refer you for support?’

Offering support to help smokers quit is more effective than telling them to quit.

Act

Referring smokers to an NHS smoking cessation service for a programme of pharmacological and behavioural support will quadruple the chance of their successfully quitting. Some people attempt to quit up to seven times before they eventually manage to do so long-term, so it is important to reassure and engage patients who say they have tried to quit before, but are still smokers (NCSCT 2017). In addition, the more action required of smokers, the less successful they will be at quitting, so arrange appointment times before they leave the consultation rather than giving them a leaflet to phone a referral system, for example.

Healthcare professionals who are trained smoking cessation advisers find that integrating making every contact count into their practice and providing ongoing support for a full 12-week (or longer) programme produces good results and increased engagement (British Thoracic Society (BTS) 2013). This is because engagement reduces the time it takes from referral to commencement.

Referral systems vary and can be arranged by contacting local services direct or contacting the national referral systems listed in Table 3.

Table 3

National referral services in the UK

CountryServices
England
Scotland
Wales
Northern Ireland

Time out 2

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National Centre for Smoking Cessation and Training making every contact count video

Find out what type of local smoking cessation services are available; how you make a referral; and relevant contact details and resources.

Examples from clinical practice

Nurses often do not realise that they are perfectly placed to integrate making every contact count into their practice (NCSCT 2012); when it is truly integrated, it can be done within existing consultation timescales.

Making every contact count helps to relate smoking with current health problems. What follows are a few examples.

During a routine examination

An advanced nurse practitioner is reviewing a patient with urinary symptoms, out of hours at a GP practice. While obtaining a history and monitoring basic observations, the nurse asks for the patient’s smoking history. The patient discloses that they smoke.

While awaiting urinalysis results and examining the patient, the nurse then advises them that smoking increases the risk of infections, such as those of the urinary tract. The nurse does this empathetically rather than lecturing the patient and incorporates this into explaining patient diagnosis and treatment.

The nurse encourages the patient to think about giving up smoking and reassures them that there is help available from the practice nurse, pharmacist and local smoking cessation service.

A routine visit

A district nurse is visiting a patient to review their leg ulcer and change dressings. They discuss progress generally and while they are reviewing the wound, the patient reveals how frustrated they are at the time it is taking for the ulcer to heal. The nurse establishes a good rapport with the patient and so brings into the conversation the patient’s current smoking habits and how this is contributing to the slow healing of the ulcer. The nurse then accepts that the patient has attempted to give up smoking, while highlighting that successfully quitting improves healing (Bernhard 2011). The nurse also mentions that most people find it takes several attempts to give up smoking before succeeding and that the local NHS smoking cessation service can help to improve the patient’s chances. The patient agrees to a referral being completed by the district nurse, which is then completed online.

Benefits for others

A community matron is visiting a patient who has a range of co-morbidities, including chronic obstructive pulmonary disease (COPD) and is a smoker. They have discussed giving up smoking on a few occasions, but the patient would not consider it.

On this visit, the patient is keen to show the nurse their new pet, a small dog. The community matron sees this as an opportunity to sensitively discuss quitting smoking, pointing out that dogs can get smoking-related diseases if exposed to second-hand smoke (VN Futures 2016). The patient is shocked at this risk and engages. They know giving up smoking will be hard, but that it is achievable with help, and so agree to a referral to a smoking cessation service and accept more support from their nurse. The patient is encouraged by the support offered and realises this is the most important element of their treatment plan so makes it a priority.

Time out 3

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National Centre for Smoking Cessation and Training making every contact count video

Consider how you could integrate the lessons from the video ‘30 seconds to save a life’ (elearning.ncsct.co.uk/vba-launch) into your current practice. What would the benefits be for your patients?

The European Respiratory Nurse Association and Education for Health offer a free e-learning module that provides an introduction to COPD at www.introtocopd.org/about

What constitutes a full smoking cessation service?

A full NHS smoking cessation service should offer at least 12 weeks of behavioural support and a course of medication, such as nicotine replacement therapy or tablets (usually varenicline or bupropion). It should be available in a range of settings, such as GP practices, pharmacies, community groups and hospitals recommended by the National Institute for Health and Care Excellence (NICE) (2012) and the BTS (2013).

As a nurse, it is important to see the rationale of why you are treating your patient. To optimise outcomes, it is also best to integrate that rationale into a treatment plan and the ongoing support given to patients. Smoking cessation should be seen as a treatment. It is a cost-effective treatment, too – one of the most cost-effective options in chronic disease management for smokers (BTS 2013). For people with COPD, for example, it offers a quality adjusted life year of £2,000 (BTS 2013), which is a tenth of the £20,000 cut-off decided by NICE (2013) as a cost-effective and good-value intervention.

Regarding smoking cessation as a treatment also adds strength to the argument that smoking cessation services should be continued in times of austerity. Unfortunately, a big problem that needs to be addressed is that many smoking cessation services are being cut due to the local government funding crisis – 59% of local authorities have cut their budgets for smoking cessation services (ASH 2017b). Healthcare professionals will find it difficult to offer advice such as ‘stopping smoking will help to reduce your blood pressure’ if they are unable to offer a smoking cessation service.

ASH (2017b) recommended that local smoking cessation services should meet NICE guidelines and standards. However, adherence to these is falling as local authorities struggle to make the savings required in their public health budgets, which are not ring-fenced and have experienced several years of severe cuts. When the evidence shows that smoking cessation services are the most effective way to give up smoking, this seems a step backwards (ASH 2016).

Behavioural support

Patients should be offered behavioural support by an evidence-based smoking cessation service (NICE 2013). This can be either one-to-one or in a group.

NICE (2013) states that group behaviour therapy should involve scheduled meetings at which smokers receive information, advice, encouragement and some form of behavioural intervention, such as cognitive behavioural therapy. These meetings should be weekly for at least the first four weeks of an attempt to quit smoking (that is, the four weeks following the date of the last smoke); however, they should preferably continue for up to 12 weeks, albeit less frequently than weekly.

A similar model should be used for one-to-one support or with small groups attempting to quit together, such as a couple, a family or a group of friends. Whatever the type of behavioural support, the main aim will be to guide the smoker through the ‘change cycle’ (Figure 2) to achieve a long-term change.

Figure 2

The change cycle

phc_v27_n8_27_0008.jpg

NICE (2012) recommends that as part of behavioural support, nurses should advise people who want to stop smoking to:

  • 1. Prepare mentally to stop by: Making a list of reasons why they want to stop.

    • Setting a date to stop smoking. This should be at a time when they feel well and are under the least amount of stress possible, but advise them to stop immediately if they are ready to do so.

    • Expecting stopping to be difficult, but progressively easier after the third or fourth day.

  • 2. Involve family and friends. If possible, stop with someone else.

  • 3. Avoid relapses by:

    • Using drug treatments such as nicotine replacement therapy to relieve the symptoms of nicotine withdrawal, which include depression, irritability and poor concentration. Explain that most of the pleasure of smoking comes from the relief of nicotine withdrawal symptoms.

    • Avoiding situations associated with smoking until they can comfortably resist the impulse to smoke. For example, they should remove smoking paraphernalia from their homes and avoid alcohol in the early stages of stopping.

    • Avoiding being around people who smoke.

    • Replacing smoking with other activities, such as exercising, chewing gum, drinking water or tea or taking glucose tablets to relieve nicotine cravings.

  • 4. Set targets for remaining smoke-free and to reward themselves for reaching these targets.

  • 5. Try again if they relapse. Most people who successfully stop smoking long-term need several attempts before they finally stop completely.

  • 6. Provide verbal and written information on:

    • The harms caused by smoking. If applicable, discuss conditions that are adversely affected by smoking, such as heart disease, peripheral vascular disease, COPD and pregnancy.

    • The health benefits of stopping smoking. Advice about the benefits of stopping should be clear, strong, and relevant to any health problems they have.

Pharmacotherapy

Nicotine replacement therapy

This replaces to some extent the nicotine a person would have received from smoking, providing a dose of nicotine to help with cravings. The dose depends on the number of cigarettes smoked, intensity and pattern of habit. NICE (2012) recommended ‘combination therapy’, which has success rates comparable to varenicline (with support) when combined with behavioural support. This involves providing a long-acting product, such as a nicotine patch, and a short-acting product. There are many varieties of the latter, most of which are absorbed sublingually, such as lozenges, gums, sprays and inhalators. The dose of nicotine is usually reduced over a 12-week period.

Patches come in two main types: 24- and 16-hours. The former is preferred if morning cravings are a problem, although their use should be reviewed if the patient’s sleep pattern is subsequently disturbed. Patches should be placed on dry, non-hairy skin (hip, trunk or upper arm), and held on for ten seconds. Application sites should be rotated from day to day.

A box containing samples of the various types of nicotine replacement products is useful to demonstrate options and a smoking cessation adviser should be able to explain all products, techniques and potential side effects (BTS 2013). Modern nicotine patches have fewer of the side effects that older patches had, such as skin irritation, and are more adhesive. This is worth mentioning when discussing options, because many smokers have tried older patches in the past and so may be cautious about using them again. It is important that the patient feels confident with the products prescribed and that these match their nicotine needs, which can be measured using a Fagerstrom Test – a tool to establish addiction and the pattern of smoking ((NCSCT) 2017). It is included in the NCSCT’s smoking cessation website with advisers who are registered on a national database.

Varenicline

This is a partial agonist that prevents nicotine reaching receptors; it also releases dopamine to help with cravings. The dose is titrated, so the patient smokes for eight to 14 days before quitting. The course of oral tablets is usually 12 weeks and is combined with behavioural support.

Bupropion

Also known as zyban, this is an older drug less commonly used now. Its primary use was as an antidepressant, but the oral tablets were found to have the beneficial side effect of assisting smoking cessation. A course usually lasts eight to 12 weeks and it should be combined with behavioural support.

Electronic nicotine delivery devices

Commonly known as vapes or e-cigs, these are electronic devices that mimic real cigarettes and release a vapour that contains nicotine. There are hundreds of different types of devices and they are increasingly used by ‘switchers’ who want a safer way of consuming nicotine, or by those attempting to quit smoking altogether.

Statutory regulation of electronic nicotine delivery devices began last year:

  • » Consumer products: manufacturers need to register their products and there are standards to which they need to adhere. Advertising is restricted.

  • » Licensed products: manufacturers can apply for a medicines licence so that their products can be prescribed and their advertising permitted. However, there are currently no licensed devices being manufactured.

A common question is whether healthcare professionals should recommend electronic nicotine delivery devices. The evidence-base is still evolving and there are some excellent resources available, including NCSCT (2016) and BTS (2017), that are updated as new evidence emerges.

More research is needed into their use, especially into their effect on smoking cessation and the safety of inhaling the vapours used, and there are arguments for and against electronic nicotine delivery devices. However, someone smoking tobacco has a greater than 50% chance of dying from a smoking-related disease, often in middle age, and while using electronic nicotine delivery devices is not risk-free, it is 95% less dangerous than smoking manufactured cigarettes (McNeill et al 2016).

Some smokers will have switched to electronic nicotine delivery devices and stopped using tobacco, while others may be using an e-cigarette to quit tobacco; some may be using both tobacco and e-cigarettes, depending on circumstances, which is referred to as ‘dual use’. We should encourage all, especially the ‘quitter’, to accept a referral to local smoking cessation services for support in quitting, as receiving behavioural support could improve their long-term chances of quitting tobacco (McNeill et al 2016).

Time out 4

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National Centre for Smoking Cessation and Training e-cigarette briefing

Read the 2016 briefing at ncsct.co.uk/shopdisp_electronic_cigarette_briefing.php and reflect on your practice and on how you can integrate asking about e-cigarette use into your practice.

Conclusion

Nurses have a pivotal role in helping people and populations to quit smoking. In times of change and financial constraint, this is going to be even more important.

Nurses need to complete brief intervention advice training – which can take as little as 20 minutes online – and integrate this into their daily practice. Following this, there is the opportunity to complete free training through the NCSCT to become a qualified smoking cessation adviser. A primary care nurse could enhance care by integrating this training into practice, especially for those with co-morbidities such as COPD.

Time out 5

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Reflect on a patient case when you could have used brief intervention advice (‘ask, advise, act’) and what message not giving such advice may have given the patient.

Time out 6

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Write a reflective account on reading this article and completing the time out sections. Visit rcni.com/reflective-account

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