Smoking cessation — making every contact count
To maximise the effectiveness of smoking cessation interventions, it is vital to seize the moment, as Beverly Bostock-Cox explains
The ‘Making Every Contact Count’ initiative was introduced in 2010 as a way of ensuring that every opportunity to deliver health promotion was taken by health care workers.1 Cigarette smoking is recognised as one of the most significant causes of ill health, including respiratory and cardiovascular disease and cancer so offering support to quit smoking is arguably one of the most important roles anyone working in healthcare can take on. In this article the rationale and evidence for smoking cessation interventions will be discussed.
THE CURRENT SITUATION
Latest statistics from the Health and Social Care Information Centre (HSCIC) indicate that in 2012, 20% of people aged 16 and over smoked. This represents an improvement from 2002 when 26% of the population smoked.2 Of those that smoke, many are keen to quit and will approach their general practice team or local NHS smoking cessation advisors for help, although it may take three or more attempts before they succeed. A report on NHS Smoking Cessation Services published in January 2015 showed that out of around 208,000 people who set a quit date with a smoking cessation advisor, approximately 50% reported success at 4 weeks.3 Motivation is an important factor in determining success when attempting to quit smoking and for many people, the cost of cigarettes is a key reasons for stopping. In the decade between 2003 and 2013, the price of tobacco increased by over 80%, making it far less affordable for most people. There is a strong link between deprivation, smoking and ill health: unemployed people are around twice as likely to smoke as those in employment, and people from deprived areas die, on average, 7 years before their more affluent neighbours. People within the professional and managerial groups also smoke, however, and in these groups the usual statistics are reversed with women smoking more than men.2 What all of these statistics tell us is that helping people to quit is an essential part of everyday healthcare provision and it is vital not to miss any opportunity to discuss smoking cessation during a consultation.
STARTING A CONVERSATION ABOUT QUITTING
Many healthcare professionals worry about annoying, irritating or nagging people about stopping smoking but in reality most smokers expect to have this conversation. It is completely appropriate to have smoking related conversations with patients attending for cytology or sexual health consultations or for appointments for minor illnesses or long term conditions which might be smoking related, or with parents bringing children to be seen or immunised. If people decide they are ready to make a quit attempt, it is worth considering whether to see the individual there and then or whether to refer on to the smoking cessation team. There is no doubt that specialist smoking cessation advisors have the knowledge and experience to support people throughout a quit attempt; however, with each referral from general practice on to another service there is a risk of losing that individual to follow up – the momentum and motivation may subside while waiting for an appointment. For that reason, general practice nurses might want to think about what they can do to strike while the iron is hot and start the process while patients wait to see the specialist smoking cessation advisor. If the individual is keen to quit and is happy to be referred on then there is no reason why the initial support and prescription should not be given from the practice nurse and/or GP. Understanding which therapies are available and the main pros and cons of these options can help the patient decide how to choose the treatment that is right for them and start on the path to a successful quit attempt straight away, with subsequent follow up being provided by the individual or team best placed to deliver long term support.
BEHAVIOUR CHANGE
The evidence shows that pharmacological therapies are less successful without behavioural support.4 Motivational interviewing can help people who are ambivalent about quitting to resolve that ambivalence. Two simple questions which are central to motivational interviewing are
- How important is this change to you?
- confident are you that you will succeed?
Asking people to give a score from 0-10 (10 being the most positive response) can identify the likelihood of success. If people give a low score it is worth asking them why they score themselves there and what might make them move higher up the scale. Motivational interviewing can help people to move through the various stages of change.5
Cognitive behavioural therapy (CBT) is a short, target based intervention that helps people to change their perception or view of an issue which is causing problems in their life. As many unhealthy behaviours are related to maladaptive reactions to stress, CBT aims to change perceptions of these problems and think of different approaches to stress management. CBT can be used very effectively even in short general practice consultations.6
Smoking cessation support
In 2013-14, 1.8 million smoking cessation prescription items were dispensed in England, down from 2.6 million a decade earlier. Spending on smoking cessation has also dropped in recent years. In 2013/14 the spend on prescription items used to help people quit smoking was nearly £48.8 million, 16% less than the £58.1 million in the previous year. At its peak, prescribing for smoking cessation was costing the NHS £65.9 million.2
According to these statistics from HSCIC, offering one-to-one support is the most widely used approach to providing smoking cessation support, with a success rate of 49%. However, telephone support had a higher success rate of 58% but was used by far fewer quitters. This offers an opportunity to think about how best to support people who are trying to quit. Although the evidence shows that a combination of pharmacological treatments and behavioural support work best, this does not mean that it has to be carried out in the practice – something which some people might find hard to do due to availability and accessibility of appointments. Offering telephone support may be a better way of helping people to quit even though this will mean that carbon monoxide monitoring cannot be carried out to confirm reducing levels in a smoker who has quit. Overall, however, the most successful venue for a smoking cessation service was in the workplace with 62% of smokers quitting through a workplace based intervention.
PHARMACOLOGICAL INTERVENTIONS
In terms of pharmacological therapies used by NHS smoking cessation services, the most common pharmacotherapy prescribed was a combination of nicotine replacement therapy (NRT) products.3 Of people given NRT, 30% had a prescription for combination NRT, with a slightly smaller number (29%) being given a single NRT product. A similar number (29%) were prescribed varenicline (Champix) and 4% received other pharmacotherapy, e.g. bupropion (Zyban). Of some concern were the 6% of people setting a quit date who were not prescribed anything as this reduces their chances of successfully quitting significantly. People who were prescribed medication showed quit rates of between 56-65%.
Dual NRT means that the individual gets a patch as a background long-acting dose of nicotine and is then given another form of shorter acting nicotine such as nicotine gum or lozenges. Patches can be prescribed as a 16 hour or 24 hour version. The Fagerstrom assessment tool for nicotine dependency states that one measure of nicotine dependence is how soon people smoke after waking. This can influence approaches to the use of NRT.7 The 24-hour patch provides nicotine in the system at all times of day and night and is often used for people who have their first cigarette of the day within 5 minutes of waking up – and overall, 16% of smokers reported having their first cigarette within 5 minutes of waking.3 Heavy smokers (those smoking 20 or more cigarettes a day) were much more likely to smoke within 5 minutes of waking than light smokers (35% and 3%, respectively). The dose of NRT should be titrated to the amount being smoked and the summary of product characteristics (SPC) for each product will recommend the dose prescribed at initiation, how to titrate down and the duration of treatment. SPCs can be found at https://www.medicines.org.uk/emc/
As well as nicotine patches and gum, there are other products such as lozenges, mouth and nasal sprays, oral films and inhalators that can be used. The key points when prescribing NRT are to use an adequate dose initially and to step down slowly when the person is ready – playing the long game pays dividends in smoking cessation. Some people worry about getting addicted to nicotine rather than cigarettes. The current body of evidence suggests that this is less harmful than smoking and although it should not be encouraged, it is better than people going back to smoking cigarettes.8
Varenicline (Champix) does not contain nicotine but ‘fools’ the brain’s nicotine receptors into thinking they are ‘full’, thus reducing cravings. Moreover, if the person taking varenicline smokes while on treatment the nicotine in the cigarette will not register with the receptors and the individual will get no pleasure from the experience of smoking – in many cases people report that it is positively unpleasant, which is another useful factor in the quit process. At the end of 12 weeks the receptors are no longer active so the patient can come off treatment without having to step down. However, this deactivation of the nicotine receptors will only happen after 12 weeks of treatment so it is essential that this element of the treatment programme is explained carefully. Too many people stop taking varenicline before the 12 week completion date, often because they feel that they do not need any more treatment as they are free of cravings. People need to know that this is because of the treatment and that stopping early will reduce the likelihood of long-term success.
Although less commonly used, bupropion (Zyban) is an option for people who cannot take other therapies or who prefer not to for whatever reason. Bupropion is a centrally acting non-nicotine therapy which is normally taken for 8 weeks.
E-cigarettes deliver nicotine via a vapour which means that the other harmful substances in cigarette smoke are no longer inhaled. A report from the Smoking in England group showed that the use of e-cigarettes is increasing.9 It has been estimated that there are 2.1 million adults who are current users of electronic cigarettes and approximately 700,000 of these are ex-smokers.10 Around 1.3 million use both tobacco and electronic cigarettes. The group Action on Smoking and Health (ASH) has published a document which offers advice on the advantages and disadvantages of e-cigarette use.10 Research continues into these products and licensing will come into effect in 2016.
Matching theory to practice
If the importance of using every opportunity to get people thinking about and acting on quitting cigarettes is acknowledged, then the impact of matching the intervention to the individual cannot be overstated. Research suggests that dual NRT and varenicline have similar success rates in helping people quit,11 so a patient-centred approach is needed to work out what is right for the individual. There are very few contraindications to either treatment regimen (although patients need to be over 18 and not pregnant to have varenicline, whereas younger people and pregnant women can be prescribed NRT) and concerns about using varenicline in people with mental health problems and long term conditions such as cardiovascular disease have long since been laid to rest.12,13 For some, the idea of taking a twice daily tablet for 12 weeks will be a straightforward option, whereas for others the idea of replacing nicotine with a patch and a top-up dose when needed will appeal. For these people, a careful discussion as to the type of top up dose and how to use it correctly will be needed. For those people who are concerned about sleep disturbance and dreams with a 24-hour patch a 16-hour patch with a fast acting top-up treatment will work well. The nicotine orodispersible films get nicotine into the system within 50 seconds of taking it, for example. However, there is no doubt that sleep disturbance and mood swings are seen in quitters using all forms of interventions, from going ‘cold turkey’ to using NRT to hypnotherapy to taking varenicline. It is worth advising people about the potential for nausea when taking varenicline.14 However, most people taking varenicline do not experience nausea, and of those who do, it usually occurs in the first week of treatment before subsiding, and can be minimised by taking the medication with food.
Complementary therapies
There is little scientific evidence for the use of complementary therapies in smoking cessation. Nonetheless, as long as interventions do no known harm, they may be useful for those people who believe that they may work. Options such as hypnotherapy and acupuncture are not normally available on the NHS however.
IN SUMMARY
Delivering support to help people quit smoking is one of the central tenets of health care. General practice nurses are perfectly placed to make every contact count when it comes to providing behavioural support and pharmacological interventions to help people quit. Expert input from the smoking cessation team is invaluable but general practice nurses should be prepared to discuss and initiate smoking cessation interventions for people who need them. Understanding basic behavioural techniques as well as the range of treatments available will enable nurses to do this effectively.
REFERENCES
1. NHS England. An implementation guide and toolkit for Making Every Contact Count, 2014. http://www.england.nhs.uk/wp-content/uploads/2014/06/mecc-guid-booklet.pdf
2. HSCIC (2014) Statistics on smoking England 2014 Available from http://www.hscic.gov.uk/catalogue/PUB14988/smok-eng-2014-rep.pdf
3. HSCIC (2015) Statistics on NHS Stop Smoking Services in England - April 2014 to September 2014 Available from http://www.hscic.gov.uk/searchcatalogue?productid=16834&returnid=3945
4. NICE (2013) Smoking cessation: supporting people to stop smoking https://www.nice.org.uk/guidance/qs43
5. Miller RW and Rollnick S (2012) Motivational Interviewing Guilford Press New York
6. David L (2013) Using CBT in general practice Scion Publishing Oxfordshire
7. Fagerstrom nicotine dependence test available from http://www.globaladdiction.org/dldocs/GLOBALADDICTION-Scales-FagerstromNicotineDependenceScale.pdf
8. Silagy C, Lancaster T, Stead L, Mant D, Fowler G. 2004. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev:CD000146
9. Smoking in England Group (2014) E-cigarettes: what we know Available from http://www.smokinginengland.info/reports/
10. ASH (2014) Electronic cigarettes Available from http://www.ash.org.uk/files/documents/ASH_715.pdf
11. National Centre for Smoking Cessation and Training (2013) Varenicline effectiveness and safety http://www.ncsct.co.uk/usr/pub/Varenicline_effectiveness_safety.pdf
12. Anthenelli R M et al (2013) Effects of Varenicline on Smoking Cessation in Adults With Stably Treated Current or Past Major Depression Ann Intern Med. 159:390-400
13. Rigotti NA et al (2010) Efficacy and safety of varenicline for smoking cessation in patients with cardiovascular disease: a randomized trial.Circulation 121: 221–229
14. Electronic medicines compendium (2014) Champix summary of product characteristics https://www.medicines.org.uk/emc/medicine/19045
