Stepwise approach to smoking cessation
With No Smoking Day falling this week, practice nurses can expect an increase in the number of patients turning to them for advice and support: we provide some pointers on what resources are available and where to find them — and more detail on how to set up a service in your own practice
Many practice nurses already provide an invaluable service in smoking cessation but when it comes to setting up a stop smoking service in primary care it's important to know how to begin and where to go to achieve accreditation.
STEP 1
OFFER VERY BRIEF ADVICE
Simple advice from a healthcare professional can have a small but significant effect on smoking cessation — more so than nicotine replacement therapy alone.1 Advice or counselling given by nurses significantly increases the likelihood of successfully quitting. However, it is unlikely to be possible to spend 10 minutes in a single consultation discussing smoking when this may not have been the primary focus of the consultation, so offer 'Very Brief Advice' to smokers at every opportunity.1
Very Brief Advice is designed to be delivered in around 30 seconds and uses the Department of Health-recommended 'AAA' approach: Ask, Advise, Act.
Ask patients if they smoke and if they have thought about stopping. You could do this when patients are identified as smokers from your records.
Advise patients that stopping smoking is the single most important thing they can do to improve their health and that of others around them.
Act on the patient's response by building confidence, giving information or referring to an NHS stop smoking service (this could be your own or another local service). (Figure 1)
STEP 2
FIND YOUR LOCAL STOP SMOKING SERVICE
Go to the NHS Smokefree site http://www.nhs.uk/smokefree and look for the nearest stop smoking service to you. Also note there are also other useful contacts and Apps you can download so you know what support is available to the smoker.
The Smokefree resource website provides lots of useful information for those delivering NHS stop smoking services, including policy updates. If you are not currently providing NHS stop smoking services, you can use the site to find out details of your nearest service so that you can refer patients. You can also order leaflets, posters and campaign information. http://www.smokefree.nhs.uk/resources
STEP 3
GET TRAINING
Once you've identified where your local stop smoking service is, it will then hopefully ensure you receive a consistent, high quality service. It will also provide you with local training that should follow a national competency framework.2
The National Centre for Smoking Cessation and Training (NCSCT) has evidence for the effectiveness of a range of Behavioural Change Techniques (BCTs). These BCTs have been incorporated into a NCSCT Standard Treatment Programme that consists of six sessions: pre-quit, quit date and four post-quit sessions.
The Standard Treatment Programme also acts as a guide to help practitioners structure the content of weekly, individual face-to-face interactions with smokers and gives examples of questions and phrases to use when undertaking interventions.
You can learn more about the Standard Treatment Programme in this NCSCT document: http://www.ncsct.co.uk/resources/training/training/ncsct-standard-treatment-programme.
What else do you need to know if you are providing NHS stop smoking services in England?
You should be aware of the Department of Health's best practice guidance for the commissioning and delivery of evidence-based stop smoking services, Local Stop Smoking Services: key updates to the service delivery and monitoring guidance for 2012/13.3 It is essential that you read this document thoroughly if you are delivering NHS stop smoking services as it sets out fundamental quality principles and includes evidence-based recommendations for interventions, the use of carbon monoxide monitoring and the provision of pharmacotherapy. This guidance recommends that all NICE-recommended treatments should be considered equally as first line, including varenicline and bupropion where appropriate. The guidance also supports the routine use of combination NRT products (more than one NRT product at a time).
The Department of Health's guidance also details the priority target groups for smoking cessation, though you will need to check local target groups with your service commissioner. The Department of Health's priority groups include:
- Routine and manual workers
- Black and minority ethnic groups
- Pregnant women
- Smokers with a mental disorder
- Children and young people
- Those who have made previous attempts to quit.
You need to be aware of NICE public health guidance on smoking cessation, particularly on prescribing and advising on pharmacotherapies.4 You also need to be aware of NICE guidance on stopping smoking in pregnancy and after childbirth.
Evidence shows that that a combination of behavioural support from a stop smoking adviser plus pharmacotherapy can increase a smoker's chances of stopping by up to four times.1 Findings from the Smoking Toolkit Study show that purchasing NRT over the counter without behavioural support has no greater effect on success rates than stopping without the assistance of medicines or support.5
Smoking induces the liver enzymes responsible for metabolising some medicines that have a narrow therapeutic index. The Department of Health's guidance recommends that stop smoking advisors establish whether clients are taking any medicines that may be affected when they stop smoking. You can find up-to-date information about clinically significant drug interactions with smoking and smoking cessation products in the October 2009 edition of the Medicines and Healthcare products Regulatory Agency (MHRA) publication, Drug Safety Update.6 (Box 1)
Harm reduction in smoking
In 2013, NICE published guidance recommending a harm reduction approach to dealing with tobacco.7
The aim of the guidance is to primarily help people who may not be able (or want) to stop abruptly, may want to stop smoking without necessarily giving up nicotine, or may not be ready to stop completely but may want to reduce the amount they smoke. While quitting smoking remains the primary objective, this alternative method will allow smokers to reduce harm to themselves and others using a different approach. (Table 1)
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 (regulated), electronic cigarettes (presently unregulated), are considered a safer alternative to smoking as they contain only nicotine and not tar, which is the primary source of harm from tobacco.
The MHRA has recommended that the Government should regulate e-cigarettes and other nicotine containing products as medicines from 2016, which will mean that they can only be marketed as an aim to cut down or stop smoking, not as a lifestyle choice.8
STEP 4
DEMONSTRATE THAT YOU'VE UNDERTAKEN LEARNING ON STOP SMOKING
Once you have worked your way through the NCSCT training and assessment programme and read the resources outlined above, you can undertake the NCSCT online assessments.2
On completion of the assessments you will be issued with certificates to demonstrate that you have passed and your name will appear on a national database.
On line assessment modules include:
- NCSCT Training and Assessment Programme - Stage 1 (Knowledge) and Stage 2 (Practice).
- NCSCT Training Very Brief Advice
- NCSCT Very Brief Advice on Second Hand Smoke
- NCSCT Speciality Modules (Pregnancy and Mental health)
- Specialist medication (soon to be released)
WHAT OTHER RESOURCES ARE AVAILABLE
Stop smoking helplines
The public Smokefree website has contact details for stop smoking helplines, including specialist helplines for pregnant women and those of south Asian origin. http://www.smokefree.nhs.uk/advice-and-information
ASH
ASH is a campaigning public health charity. Its website contains lots of facts and figures about smoking prevalence, who smokes and the effects of smoking, which are useful if you intend to do talks to community groups, schools, etc. http://www.ash.org.uk/information
No Smoking Day
This is an annual campaign held in March to focus attention on stopping smoking. You can order leaflets, posters, etc. to support the campaign from the campaign website: http://www.nosmokingday.org.uk
Stoptober
This is an annual campaign held in October each year to encourage smokers to stop smoking for a month. Research shows that those who stop smoking for 28 days are five times more likely to stay stopped.
National smoking cessation conferences
These are annual conferences for those interested in stop smoking services:
UK National Smoking Cessation Conference http://www.uknscc.org
CONCLUSION
Being a stop smoking advisor is one of the most rewarding careers there is, and can fit neatly into a nurse's day in primary care. It is cost-effective to both the client and the NHS, and more importantly, it saves lives. For every two people a practitioner helps to stop smoking, one life is saved. To put things into perspective you would need to do 1,040 cervical smear tests to save one person's life!9
This article will hopefully help you begin a long and fruitful journey in helping your patients overcome one of the most powerful addictions.
REFERENCES
1. NHS Stop Smoking Service: service delivery and monitoring guidance 2011/12. Available at: http://www.ncsct.co.uk/usr/pub/delivery-and-monitoring-guidance-2011-and-2012.pdf
2. National Centre for Smoking Cessation and Training. Training standards and resources. Available at: www.ncsct.co.uk
3. Department of Health. Local Stop Smoking Services: key updates to the service delivery and monitoring guidance for 2012/13. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216927/9193-TSO-2900254-NHS-Stop-Smoking_Accessible.pdf
4. National Institute for Health and Care Excellence. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. www.nice.org.uk/PH010
5. West R, Lesley O. Estimates of 52-week continuous abstinence rates following selected smoking cessation interventions in England. STS120301 March 2012. Available at: http://www.smokinginengland.info/sts-documents/
6. Medicines and Healthcare products Regulatory Agency publication, Drug Safety Update. 2009;3(3). Available at: http://www.mhra.gov.uk/Publications/Safetyguidance/DrugSafetyUpdate/CON059804
7. National Institute for Health and Care Excellence. Tobacco: harm reduction approaches to smoking. June 2013. Public health guidance PH45.Available online at www.guidance.nice.org.uk/ph45
8. Medicines and Healthcare products Regulatory Agency (MHRA) advice on nicotine containing products, available online at: http://www.mhra.gov.uk/Safetyinformation/Generalsafetyinformationandadvice/Product-specificinformationandadvice/Product-specificinformationandadvice%E2%80%93M%E2%80%93T/NicotineContainingProducts/index.htm
9. Gates TJ. Screening for cancer: evaluating the evidence. Am Fam Phys 2001;63:513-523
