Smoking cessation: Tailoring your approach to the individual smoker

Smoking continues to cause more preventable deaths than any other risk factor — one reason why the current 'Stoptober' campaign is being promoted so intensively. So what questions can nurses ask to help smokers quit?

The prevalence of smoking in England is around 20%.¹ Smoking causes more preventable deaths than anything else - nearly 80,000 in England during 2011. There are still more than 8 million smokers in England. By the end of 2015, the Department of Health want to reduce smoking rates to:

• 18.5% or less for adults (compared with 21.2% for April 2009 to March 2010) meaning around 210,000 fewer smokers per year
• 12% or less for 15 year olds (compared with 15% in 2009)
• 11% or less for pregnant women, measured at the time of giving birth (compared with 14% over 2009 to 2010)

Research suggests approximately 70% of smokers want to stop.^3,4

More than a third of all smokers make at least one attempt to stop in a given year but only about 4.8% of smokers succeeded long term in 2010.⁵ It is not clear why some attempts to stop succeed and others do not, though smoking fewer cigarettes per day, not needing to smoke first thing in the morning and not suffering from mental health problems or other addictions are favourable factors for success.

EVERY SMOKER WE COME ACROSS IS DIFFERENT

Many factors make it difficult to stop smoking including:

• Pharmacological dependence on nicotine — cigarettes are so addictive because of the rapid delivery of a high dose of nicotine to the brain stimulating the 'reward centre'⁶
• Physiological dependence on nicotine — Major motivation to continue smoking is avoidance of negative mood states caused by withdrawal of nicotine⁷
• Psychological/emotional barriers (e.g. for stress relief)
• Behavioural/social: Situations become linked to smoking such as at home watching the TV, driving the car and socialising (looking 'cool')⁸
• Sensorial factors (enjoyment of smoking, feel of cigarette in hand, taste/sensory experience)^9,10

Smoking is an integral part of many smokers' lives, particularly for long term smokers. To a person who smokes, quitting means much more than just overcoming the pharmacological effects of nicotine; it effectively means changing their lives: sometimes changing their friends or their behaviour with their friends or work colleagues. It will involve changing their regular routines to avoid situations in the day where they might usually light up e.g. when driving in the car. If we take the above factors in to consideration, it will help us understand that there is no 'one size fits all' in the treatment of smoking cessation. We therefore need to tailor our stop smoking support programmes to each smoker and try out proven strategies that may work for the individual we are helping.To do this we need to first understand what's going on in the smoker's world by asking some simple but vitally important questions.

BEHAVIOURAL FACTORS

Assessing motivation and confidence, looking at past quit attempts

Asking open questions gives the patient an opportunity to express any concerns and to be listened to, and this is important when building rapport. For example, 'Why do you want to stop smoking?'

Looking at previous quit attempts is an important part of assessing motivation and confidence. Ask, 'When you previously quit, what do you think went well and what didn't?', 'What do you think you will do differently this time around?', 'Do you have any concerns about stopping and if so, what are they?'

If someone has had multiple quit attempts, reassure them that the more times they try to stop smoking, the more likely they are to quit as each attempt is a learning process. Obviously don't mention this if it is their first attempt!

PHARMACOLOGICAL FACTORS

Assessing nicotine dependence is useful, as it will provide you and the patient with an understanding of what type of cravings the smoker needs to overcome and to assist with choice of medication.¹¹

Ask:

How soon after getting up in the morning do you have your first cigarette?

Do you smoke when you're ill in bed?

Do you find it hard to refrain from smoking when you're on a plane or in a cinema etc?

Do you get up in the middle of the night to smoke?

CHOICE OF MEDICATION

There are now eight different formats of NRT and also two non-nicotine treatments, which can make it difficult for advisors to help provide an informed choice to help the client.

NICOTINE REPLACEMENT THERAPY (NRT)

To help us better understand the treatments that are available the graph overleaf highlights how products can vary in blood concentrations and speed of action in the first hour. (Figure 1)

Some of the questions that I use in my group sessions may help you when deciding on what the most appropriate NRT product is for an individual:

Speed of Action

On a scale of 1 to 5 (where 1 is low and 5 is high), how important is it for you that the product can control cravings quickly? (If rated 4 or 5, consider a fast acting product such as an oromucosal spray (mouth spray), or nasal spray as these are the only licensed products on the market to reach high concentrations within the first 10 minutes.

Strength and Dose

How many cigarettes do you smoke a day? Are there times when you might smoke more?

How long have you been smoking x cigarettes? (Sometimes clients reduce the number, if they've recently cut down)

How soon after getting up in the morning do you have your first cigarette?

Do you get up in the middle of the night to smoke?

If you sense their nicotine dependency is high then consider recommending the highest strength NRT products in combination from the very first day of the quit attempt e.g. high strength patch with high strength short acting product.

It's important to not be too concerned with over-dosing (as the graph demonstrates); if anything we should be more concerned with under-dosing.

Question for advisor only to consider —

On a scale of 1 to 5 how dependent on nicotine do you feel the individual is? If 4 or 5 — consider high strength combination NRT, if a 3 consider high strength patch with lower strength short acting product, if 1 or 2 consider high strength monotherapy

Behavioural/Social/Sensorial

On a scale of 1 to 5 (where 1 is low and 5 is high), how important is it for you to have a product that looks like a cigarette? (If rated 4 or 5, consider an Inhalator in combination with a patch.)

Technique

The stop smoking advisor should offer accurate advice on the NRT products and watch the patient using it to ensure proper usage. Unfortunately poor technique is one of the main reasons why patients terminate their treatment.

To give you a couple of examples:

Nicotine patch — some people discontinue use if they get any form of skin irritation or redness (this is one of the common side effects). They can continue using the product if this happens.

Mouth spray — it's important patients are shown how to break the seal and open the child resistant container as they need to dispense a fine mist rather than a jet.

Question: After explaining and demonstrating technique which product appeals to you most?

On a scale of 1 to 5 how much does this product appeal to you? If lower than 4 suggest an alternative product.

Length of course

It's important that patients stay on their treatment for a minimum of 8 weeks to get the best possible outcome. This will need to be explained to them.

Question: On a scale of 1 to 5 how important do think it is to stay on your treatment for a minimum of 8 weeks? If they say 4 or 5 acknowledge that's right and it will greatly improve their chances of stopping and staying stopped. If less than 4 then highlight that this is one of the biggest reasons why people go back to smoking as the cravings can hit them when they least expect it.

Top Tip

(For all medication discuss)

• Technique
• Strength and dosage
• Treatment duration
• Problems with irregular use

NON-NICOTINE TREATMENTS

There are two licensed non-nicotine treatments, varenicline (Champix) and buproprion (Zyban) that are available in the UK on prescription.

A Cochrane review of the results from nine research studies (with over 7,000 smokers) found that, compared with placebo, varenicline more than doubled long-term abstinence rates.

Clinical trials indicate that varenicline is almost twice as effective as bupropion and is almost certainly more effective than single forms of NRT.

Refer to the Summary of Product Characteristics (SPC) for a full description of each product.

UNLICENSED TREATMENTS

Electronic cigarettes

Around 1.3 million people in the UK use electronic or 'e-cigarettes'. They work by heating a solution of nicotine and propylene glycol or glycerine to produce a vapour that can be inhaled.

Puffing on e-cigarettes is commonly known as 'vaping' as no smoke is produced.

There is no ban on public 'vaping' as there is with smoking in public places. This means that it is legal to 'vape' in pubs, restaurants etc.

At present there are no controls on manufacture of e-cigarettes and an analysis of different brands revealed varying amounts of nicotine in each, as well as different excipients.¹²

The Medicines and Healthcare products Regulatory Agency (MHRA) has decided that e-cigarettes and other nicotine-containing products should be regulated as medicines from 2016. This will mean that they can only be marketed as an aid to cut down or stop smoking, not as a lifestyle choice.¹³

NICE public health guidance states that there is little evidence on the effectiveness, quality or safety of unlicensed nicotine products but they are expected to be less harmful than tobacco.¹⁴

In summary, while more research is still needed on products such as e-cigarettes on efficacy and safety, they do show great promise as experienced users who are smokers/ex smokers are actively using them, and they should — in theory — reduce harm to the individual.

HARM REDUCTION STRATEGIES

New guidance from the National Institute for Health and Care Excellence (NICE) has recommended a harm reduction approach to dealing with tobacco use.¹⁵

The aim of the guidance is to primarily help people who may not be able (or want) to stop abruptly, who may want to stop smoking without necessarily giving up nicotine, or who may not be ready to stop completely but may want to reduce the amount they smoke. While quitting smoking remains the primary message this alternative method will allow smokers to reduce harm to themselves by using a different approach.

In the guidance, nicotine replacement therapies are advocated as a less harmful alternative to smoking tobacco and should be recommended to smokers who are unable or unwilling to quit completely in order to help them cut down.

Nicotine replacement therapies (licensed), electronic cigarettes (presently unlicensed), are considered a safer alternative to smoking as they contain only nicotine and not tar, which is the primary source of harm from tobacco.

SUMMARY

Smoking is a complex addiction

This article highlights the many factors that make it difficult to stop smoking beyond the pharmacological effects of nicotine. Our help as advisors is needed more than ever to help support the remaining 10 million smokers in Great Britain,16 and to continue saving lives.

The fact is that there are a variety of methods that work, and what works for one person may not work for another, and that if one approach isn't successful, a different approach may achieve the desired goal.

Setbacks are a natural part of quitting. Providing stop smoking support is proven to be effective regardless of how many quit attempts a smoker has.¹⁷

Finally, referring a patient to a local stop smoking service means they are four times more likely to stop smoking.

REFERENCES

1. Office for National statistics March 2013. http://www.ons.gov.uk/ons/dcp171776_302558.pdf.

2. Healthy Lives, Healthy People: A Tobacco Control Plan for England (pg 6)

3. Lader D, Goddard, E. Smoking-related behaviour and attitudes. Office for National Statistics. 2004

4. Smoking-related behaviour and attitudes, 2007. Office for National Statistics. 2008

5. West R, Brown . Smoking and Smoking Cessation in England 2011: http://www.smokinginenglandinfo/.

6. Nicotine addiction in Britain: A report of the Tobacco Advisory Group of the Royal college of Physcians. London: Royal College of Physicians, 2000

7. Nicotine addiction in Britain: A report of the Tobacco Advisory Group of the Royal college of Physcians. London: Royal College of Physicians, 2000

8. Van Gucht D, et al. J Behav Ther & Exp Psychiat. 2010;41:172-177

9. Fagerstrom K. Determinants of tobacco use and renaming the FTND to the Fagerstrom Test for Cigarette Dependence. Nicotine Tob Res 2012;14:75-78

10. Rose JE. The role of upper airway stimulation in smoking. Prog Clin Biol Res 1988;261:95-106

11. Heatherton, Todd F. et al. 1991 The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. British Journal of Addiction 86:1119-1127

12. Commission on Human Medicines, working group on nicotine containing products. Assessment of the constituents of four e-cigarette products. Available at: http://www.mhra.gov.uk/Safetyinformation/Generalsafetyinformationandadvice/Product-specificinformationandadvice/Product-specificinformationandadvice%E2%80%93M%E2%80%93T/NicotineContainingProducts/index.htm

13. Medicines and Healthcare products Regulatory Agency (MHRA) advice on nicotine containing products, available at: http://www.mhra.gov.uk/Safetyinformation/Generalsafetyinformationandadvice/Product-specificinformationandadvice/Product-specificinformationandadvice%E2%80%93M%E2%80%93T/NicotineContainingProducts/index.htm

14. NICE. Public health guidance PH45. Tobacco: harm reduction approaches to smoking. June 2013. Available at www.guidance.nice.org.uk/ph45

15. NICE. Public health guidance PH45. Tobacco: harm reduction approaches to smoking. June 2013. Available online at www.guidance.nice.org.uk/ph45

16. ASH. Facts at a glance: smoking statistics. Available at: http://www.ash.org.uk/files/documents/ASH_93.pdf

17. Fu S, Partin M, Snyder A, An LC, Nelson DB, Clothier B, Nugent S, Willenbring ML, Joseph AM. (2006) Promoting repeat tobacco dependence treatment: are relapsed smokers interested? American Journal of managed Care 2006; 12 235—243