Smoking cessation: What works?

Halfway into 'Stoptober' - like October but without cigarettes - what can practice nurses say or do to help patients make it through to the end of the month, and with any luck, quit for good?

The latest initiative to encourage people to give up smoking is 'Stoptober' - a campaign launched at the start of the month urging smokers to quit for 28 days until the end of October.

The campaign is unique in that it is the first mass quit attempt of its kind, encouraging the UK's 8 million smokers to give up for a whole month. The rationale is that if smokers can stop for 28 days, they are five times more likely to stay smoke-free.

While 65% of smokers claim that they want to stop, relatively few - only 38% - actually make the attempt. Most smokers who try to quit have tried and failed before. Although there are around 5 million attempts to quit each year in England, only 7% succeed in stopping for one year.¹

While smoking rates have declined over past decades, the rate of decline has slowed in recent years. It remains the biggest cause of premature death in England, accounting for more than 100,000 deaths in the UK. One in two long-term smokers will die prematurely from a smoking-related disease.¹

It is too soon to say how many people have taken up the challenge, although the Department of Health did run a 28-day trial in advance of October so that it would have some case studies to demonstrate that the approach works.

The campaign is backed by leading charities, including Cancer Research UK and the British Heart Foundation, and has been supported with a multi-media campaign, including Twitter, TV and press advertising. For participants, there is a Facebook page, expert advice, support materials, a mobile phone app and daily text messages.

WHY 28 DAYS?

The prognosis for permanent cessation improves the longer that the attempt persists, improving five-fold in the first 4 weeks.² The risk of relapse with time is very high in the first 4 weeks and becomes very low after the 12-week point.² (Figure 1)

REDUCING SMOKING OR ABRUPT QUITTING?

The standard way to stop smoking is to smoke as usual until a 'quit day' at which point the smoker stops and doesn't smoke again. However, most smokers who try to stop end up relapsing suggesting that this approach doesn't work for everyone.³ An alternative way to give up could be to reduce the number of cigarettes smoked before going on to stop completely. A Cochrane review³ of ten studies that compared reducing smoking before quitting with abrupt quitting found that neither approach was superior to the other, regardless of whether the attempt to stop smoking was made with or without nicotine replacement therapy (NRT). This suggests that smokers should be given a choice of methods, either reducing smoking before quitting or quitting abruptly.³

BEHAVIOURAL SUPPORT

Behavioural support can be very useful in helping smokers to stop. In a cluster randomised study, smokers in primary care practices in the US that had a system in place to refer smokers to an evidence-based quit line had higher sustained quit rates than smokers in practices that did not have a referral system.⁴

Any kind of motivational or behavioural support needs to be predicated on an understanding of why people smoke. According to Professor Robert West,⁵ Director of Tobacco Studies at the Cancer Research UK Health Behaviour Unit, and Professor of Health Psychology, University College, London:

• They light up and puff on impulse - much smoking is habitual, done without thinking
• They want or need to - they expect to enjoy it, and experience a 'hunger' for a cigarette after a period of not smoking
• They think it serves a purpose - they expect it to help with stress, weight control and concentration
• They form plans to smoke e.g. they plan to go for a cigarette during coffee breaks
• These motivations are stronger than any competing motivations including a plan not to smoke.⁵

Smokers therefore often need behavioural support to maximise their desire not to smoke (during a quit attempt) and increase their capacity for self-control.⁶

Approaches aimed at reducing the desire to smoke include:⁶

• Avoiding cues to smoke
• Distraction
• Exercise
• Medication
• Promoting new identity as a non-smoker

Self-control stems from commitment to specific rules e.g. I do not/will not smoke, sufficient mental energy (so avoid competing demands such as stress or simultaneously trying to lose weight), and being able to develop skills to respond to cues to smoke.⁶

Systematic reviews show clear benefits from individual face-to-face, group face-to-face, telephone based or internet-based support. On average, behavioural support helps approximately one in 20 smokers at each quit attempt; the benefit appears to accumulate with successive quit attempts.⁶

BRIEF INTERVENTIONS

There is a body of evidence directly applicable to UK health care settings that supports the efficacy of GP opportunistic advice, and for nurse structured advice as brief interventions for smoking cessation.⁷ Brief interventions have been shown to be cost effective.⁷

A brief intervention can be summed up by the 5 A's.

1. Ask about a patient's smoking status

2. Advise those who smoke to stop

3. Assess their readiness to stop

4. Assist smokers in their stopping attempts

5. Arrange follow up.⁴

PHARMACOLOGICAL SUPPORT

Nicotine is highly addictive. When it is absorbed it attaches to receptors in the brain, stimulating dopamine release. Although the resulting sensation may be only mildly pleasant, repeated ingestion of nicotine alters motivational pathways creating an urge to smoke, which increases over time since the last cigarette. It usually reduces over weeks of not smoking but can re-emerge unexpectedly. Abstinence results in unpleasant withdrawal symptoms, including depression.⁶

Pharmacological support is available in two modalities - NRT, or medication to reduce the urge to smoke.

NRT

NRT provides an alternative source of nicotine, at a lower level than from cigarettes, and without the tar, carbon monoxide and other toxins present in tobacco smoke.⁸

NRT is available as patches, chewing gum, inhalators, tablets/lozenges, nasal spray or mouth spray. There is no evidence that one particular type of NRT is more effective than another, and which one is used depends on personal preference and also on the smoker's habits. Heavy smokers may find a 24-hour patch useful as it helps to reduce cravings on waking, but others may prefer NRT spray formulations because they are faster-acting. Some smokers find that using a combination of products is most helpful, for example, patches to control cravings or withdrawal symptoms plus an add-on 'on demand' form such as gum or an inhalator to reduce the urge to smoke at particular times, such as after a meal. Nicotine patch plus lozenges have been shown to produce the greatest benefit relative to placebo.

Medication

The two medications available on the NHS to help smokers to stop are buproprion and varenicline.

Bupropion was originally developed as an antidepressant but it was found to help people stop smoking, possibly through action on the parts of the brain involved in addiction. When given in association with behavioural support, bupropion is as effective as NRT, and like NRT leads to a near doubling of the smoking cessation rate, achieving long term abstinence in 19% of smokers who use it to quit.⁹

Varenicline is currently the only medication that is specifically designed to help smokers to stop smoking. It works by preventing nicotine from binding to receptors in the brain, thus easing cravings and reducing the rewarding and reinforcing effects of smoking.⁸

In head to head trials, the continuous quit rate for weeks 9-12 was statistically greater for varenicline than for bupropion. In a meta-analysis of 70 NRT trials, 12 bupropion trials and 4 varenicline trials versus control or placebo, at 12 months varenicline was superior to NRT and bupropion.¹⁰

CONCLUSION

The Stoptober campaign may provide added impetus for the UK's smokers to give up, or at least to try. If any of your smoking patients come into the surgery, it provides an opportunity to ask how they are getting on... if they have managed to stay off the fags until now, tell them 'Well done, and keep up the good work'. If they have tried but failed, remind them that it often takes several attempts before a smoker succeeds in becoming an ex-smoker. There are all sorts of things that can help, from brief opportunistic advice to one-to-one support from a trained counsellor, and from NRT to prescription-only drugs - whatever support you can provide will increase your patient's chances of success.

REFERENCES

1. Department of Health. 'Stoptober' Smokefree Campaign communications toolkit. September 2012
2. West R, Stapleton J. Clinical and public health significance of treatments to aid smoking cessation. Eur Respir Rev 2008;17:199-204
3. Lindson N, Aveyard P, Hughes JR. Comparing reducing smoking to quit with abrupt quitting. Cochrane Summaries 2010 Available at: http://summaries.cochrane.org/CD008033/comparing-reducing-smoking-to-quit-with-abrupt-quitting 4. Smoking Cessation. BMJ Best Practice 2011. Available at: http://bestpractice.bmj.com/best-practice/monograph/411/treatment/step-by-step.html 5. West R. The PRIME theory of motivation and its application to smoking cessation. Presentation at UK National Smoking Cessation conference 2006. http://www.uknscc.org/2006_UKNSCC/speakers/robert_west_1.html 6. West R. Understanding, preventing and treating addiction to cigarettes through the lens of PRIME Theory. February 2009. Available at: http://www.primetheory.com/prime-resources-slides.php 7. NICE. Brief interventions and referral for smoking cessation in primary care and other settings. Public Health Intervention Guidance 1. Available at: http://www.nice.org.uk/nicemedia/live/11375/31864/31864.pdf 8. NHS Choices. Smoking (quitting) - treatment. 2012. http://www.nhs.uk/conditions/smoking-(quitting)/Pages/Treatment.aspx 9. Roddy E. Bupropion and other non-nicotine pharmacotherapies. BMJ 2004;328:509-11
10. NICE. Varenicline for smoking cessation. Technology appraisal guidance 123. http://www.nice.org.uk/nicemedia/pdf/TA123Guidance.pdf