Tobacco: Reducing the harm

Traditionally, health care professionals took an absolute view on smoking – ‘smokers should quit, completely’, and simply cutting down was not good enough. But NICE guidance now recognises that for some people, giving up is not always easy and limiting the harm is the next best thing

The earliest reference to tobacco smoking comes from two Spaniards writing in 1492 who saw American natives ‘drinking smoke’.¹ Allegedly introduced into Britain by Sir Walter Raleigh, smoking rapidly became popular so that by 1948, 65% of male adults in the UK smoked cigarettes.² King James I famously described smoking as:
‘Hateful to the nose, harmful to the brain and dangerous to the lungs’.³

In 1642 the Pope threatened snuff users with excommunication. In Turkey smoking was a capital offence while the Emperor of Russia ordered that ‘tobacco drinkers’ should have their noses slit.¹ And all without reference to randomised controlled trials.

Tobacco is remarkable stuff. Tobacco smoke can be at the same time an aid to concentration and also to relaxation, a rare combination of properties. In addition, inhalation is a very rapid means of getting nicotine to the brain,³ indeed rather quicker than by intravenous injection. If smoking were not so dangerous, cigarettes would probably be available on prescription.

There is compelling evidence that cigarette consumption can be reduced by price regulation⁴ and by the banning of cigarette advertising.⁵ Indeed successive governments have increased the duty on tobacco more rapidly than inflation to make smoking relatively more expensive, and have also introduced significant restrictions on tobacco advertising. Now that a single cigarette costs about 40p (that is, if it is not smuggled into the country as up to 30% of them are⁶) it is no longer a cheap treat. On the contrary, it is an expensive addiction, and this is where government policy, public health and primary healthcare get intermingled. It may well be that government policy is the best way of reducing tobacco consumption, but in primary care, patients who smoke present as individuals with a problem to which their habit is adding. Whatever the ethics, primary care practitioners have to have a way of dealing with smoking patients.

THE STATISTICS

There has been a gradual decline in cigarette smoking since 1948, but this now seems to be levelling off. At present about 20% of adults smoke. There is a social class gradient, in that 27% of manual workers smoke, but only 13% of professional workers do so.⁷

In 2011 smoking caused 79,000 deaths, and another 11,000 people died in England because of second-hand smoke (passive smoking).⁸ About half of regular smokers will be killed by their habit; a quarter prematurely and a quarter in old age.⁹ A rough calculation suggests that each cigarette shortens life expectancy by 11 minutes.¹⁰ The NHS cost of smoking is around £2.7 billion a year. However, this is only the tip of the iceberg as the overall cost of smoking to the nation (financial benefits, lost production etc) is nearly £14 billion a year. The revenue from tobacco duty is around £10 billion a year, so in 2010 it was calculated that each cigarette smoked costs the country 6.5p.¹¹

Nearly all smokers know that it is bad for them, and two thirds want to stop. There are now more ex-smokers than smokers in the UK.⁷ So why don’t they all just stop? It is, of course, not that simple. Some peoples are genuinely addicted to their cigarettes, and even more fear that they are addicted and will find it impossible to stop. For some a cigarette is a welcome break in the tedium of reality, a deserved and reliably comforting reward. The diseases caused by smoking tend to be those of old age, so that they do not apply to the young smoker who may also think that he or she has plenty of time to quit. All smokers , irrespective of age, benefit from stopping, and after 15 years of stopping their risks of heart attack and lung cancer are nearly the same as if they had never smoked.¹²

ROLE OF THE PRACTICE NURSE

Practice nurses have plenty of opportunities to talk to patients about their smoking. As the vast majority of chronic disease management in UK primary care is now undertaken by practice nurses, there is a steady stream of people with ongoing problems for whom stopping smoking is even more of a priority. Indeed I would speculate that within the population of patients in regular contact with a practice nurse that the prevalence of smoking is substantially greater than in the community generally. There are people with diabetes, with hypertension, those recovering from strokes and heart attacks, COPD patients kept prisoner by their oxygen supply. For these groups staying off the cigarettes is more immediately a matter of life or death, and in many cases the patients would not be in such a mess if they hadn’t smoked in the first place.

But being nagged about the dangers of smoking is unlikely to have much effect, as the psychology of smoking is far more complex than that. Also, people are unlikely to stop smoking unless they are ready to do so. Here the Stages of Change model¹³ can offer insights into why some people won’t change, and why others try repeatedly to stop smoking and fail. But there are things that a practice nurse can do to help a patient to quit smoking, and there are ways that the primary care team can reinforce this message.

‘Brief advice’ delivered by a doctor has been shown to help in a modest way – 2.5% stop.¹⁴ Since practice nurses do most things better than doctors, it can confidently be expected that practice nurses will be at least as successful. The advice is designed to be provided in 5 to 10 minutes, and comprises:

• Suggest that it would be a good idea to stop
• Assess willingness to quit
• Offer drug or behavioural support
• Provide self-help materials

Increasingly such packages of care, particularly if they are backed up with a prescription, are run by community pharmacies (who get paid for the service) or more specialised community based smoking services. Some groups are particularly targeted: my local obstetric unit has dedicated midwives to reinforce smoking cessation.

PHARMACOLOGIGAL SUPPORT

The use of medications significantly improves the efforts of people who want to stop smoking. A packet of 20 cigarettes now costs about as much as a prescription charge. Nicotine replacement therapy (NRT) comes in patches (probably the most popular), gum, lozenges, oral spray, nasal spray and an inhalation cartridge, which also mimics the act of smoking a cigarette so that all the psychological manifestations of smoking are covered. Unsurprisingly, NRT contains nicotine, the addictive component of cigarette smoke, but it does not contain any of the other 4000 chemicals found in tobacco smoke, and in all situations is considered to be safer than smoking.

Bupropion was originally designed as an antidepressant and is still used for this especially in Australia. Its mode of action on cigarette craving is not clear. Side effects include dry mouth, abdominal pain, depression and anxiety. It should not be used in severe liver cirrhosis, epilepsy or bipolar disorder.

Varenicline can also cause a dry mouth and gastrointestinal disturbance. It can also lead to depression or anxiety, and the British National Formulary advises that patients should be warned that it may lead to suicidal thoughts and behaviour.¹⁵ Talk about ‘dying for a cigarette.’

But medication is effective. When the Cochrane team14 ran some literature reviews in 2008 they worked out the effectiveness of medication in terms of Number Needed to Treat (NNT) to achieve one successful cigarette quitter when compared with placebo. They concluded:

NRT (all types): NNT = 23

Bupropion NNT = 18

Varenicline NNT = 10

This means that for every 23 people who try NRT one will stop smoking long term: a modest effect, but it’s a start.

A CHANGE OF PERSPECTIVE

Until recently, the emphasis on the management of smoking has been to get people to stop. By this strict parameter, the methods available have a disappointing impact. However, thoughts are now turning to consider whether reducing the number of cigarettes smoked, or achieving temporary (but not permanent) breaks in a smoking career may be useful aims as well. There are precedents: workers with COPD will now usually express smoking risk burden in ‘pack years’ – how many packs (of 20 cigarettes) a day for how many years; in work with heroin addicts, it is clear that those who stay in treatment programmes, even if this does not result in a complete stop in all drug use (including methadone), are less likely to end up dead.

So NICE has developed guidance that makes the point that if you can’t quit, then reduced consumption is the next best outcome.⁸ NRT is already licensed for harm reduction in smokers, not just for quitting purposes (this in fact is already happening – lots of people try repeatedly to use NRT, and carry on smoking as well, especially since NRT can be bought over the counter). It is suggested that NRT (but not other anti-smoking drugs) can be used possibly in the long term over years, without a date ever being set to stop. Also NRT can possibly be used in combinations with (say) a patch for gradual delivery supplemented by gum for an acute craving.

This new perspective on tobacco harm reduction is not without its critics. People are ‘allowed’ to stay addicted to nicotine, which suits the cigarette industry. People can use NRT forever, at public expense, which suits the pharmaceutical industry. With such bedfellows, NICE may leave itself open to criticism.¹⁶

A CULTURAL PERSPECTIVE

In the UK tobacco has traditionally been smoked. However, this is not the only way of using tobacco, and in some cultural groups it is more likely to be chewed. Chewing tobacco is associated with mouth cancer, heart disease and gum and tooth disease.¹⁷ So NICE has also produced guidance aimed at the South Asian community to make tobacco use reduction services available for those who chew tobacco as well.¹⁸ The recommendations cover the use of ‘brief advice’ and more intensive behavioural interventions, but not the use of medication. These recommendations will be more applicable to nurses who work in areas with a South Asian community.

CONCLUSION

The use of tobacco continues to be a significant public health menace in the UK. Deaths attributable to tobacco far outstrip those attributable to any other drug of abuse. There is a rump of people who continue to smoke, and because of their behaviour and the associated problems they are highly likely to come to the attention of the practice nurse.

Guidance to reduce the harm caused by smoking rather than just look at quitting smoking is long overdue, and almost certainly reflects what primary care workers are already doing: cutting back or stopping for a bit is not as good as stopping permanently, but it’s better than nothing.

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