Practice Nurse

Smoking cessation

Although the numbers of adults who smoke tobacco has declined sharply in recent decades, smoking remains the main cause of preventable morbidity and premature death: in England alone it led to an estimated annual average of 86,500 deaths between 1998 and 2002. Smoking is the main reason for the gap in life expectancy between social classes.

In addition to the better-known increased risks of cancers, respiratory diseases and coronary heart disease, tobacco smoking causes stomach and duodenal ulcers, erectile dysfunction, infertility, osteoporosis, cataracts, age-related macular degeneration and periodontitis. It contributes to lower post-surgery survival rates, delayed wound healing and post-operative complications.

Simple advice from a healthcare professional can have a small but significant effect on a patient succeeding in giving up smoking, and helping someone to stop smoking is one of the most cost-effective interventions a practice nurse can make.

This resource, consisting of ten assessment questions at basic and intermediate levels, tests your knowledge of the factors that may improve your patients’ chances of successfully stopping smoking. Complete the resource, including the recommended reading and some or all of the suggested activities to obtain certificates for two hours of continuing professional development to include in your annual portfolio.

On completion of this module you should be able to:

Understand the economic and health burden that tobacco smoking inflicts on the UK

Discuss with a patient the risks of smoking

List the medications that the NHS can provide to help smokers to stop

Calculate a patient’s total lifetime consumption of cigarettes in ‘pack years’

Help a patient to construct a personal ‘Advantages & Disadvantages of smoking’ list

NICE. Smoking overview (including preventing uptake of smoking in children and young people, tobacco harm-reduction approaches, cardiovascular risk, stop smoking services and smokeless tobacco cessation). 

https://pathways.nice.org.uk/pathways/smoking

Smoking cessation – tailoring your approach to the individual smoker

What percentage of adults in the UK smokes tobacco?

According to the campaign group Action on Smoking and Health (ASH) at present about 20% of adults in the UK smoke tobacco. This is a long way down from the peak in 1948 when 65% of adults smoked manufactured cigarettes and 82% smoked tobacco in some form. At that time smoking was permitted nearly everywhere, smoking featured in most of the Hollywood films that were so popular, and cigarettes were given out in the rations to service personnel during both World Wars.

However, this decline in smoking now seems to be levelling off: NHS Stop Smoking services are in decline, and in the past 12 months, the number of people who set a quit date with NHS Stop Smoking services has fallen by 19%.

The policy think tank Policy Exchange estimated in 2010 that tobacco smoking cost the NHS £2.7 billion a year. This has to be an estimate, but is based on the probable effect of smoking on the prevalence of a number of serious and life-threatening illnesses such as stroke, heart attack, and COPD. The estimate includes investigation and treatment costs, time in hospital, and the time of the professionals looking after them.

Find out from your colleagues or your local hospitals the cost of some procedures that you feel have an important impact on healthcare (e.g. a hip replacement, an elderly care place in a nursing home). Then reflect on how the money saved by the NHS if patients did not smoke could be spent.

Question 1

What proportion of smokers die from a smoking-related disease?

About 50% of smokers will die of a smoking-related disease process, and in half of these cases the death will be premature. These estimations are based on pioneering work done in the 1950s using a group of doctors – at that time doctors were more likely than the overall population to smoke.

Approximately 90,000 smoking-related deaths occur each year in England alone. This estimation was made by NICE based on figures from 2011. It consists of 79,000 smokers and a further 11,000 people who have been exposed to tobacco through passive smoking.

Peto R. Smoking and death: the past 40 years and the next. BMJ 1994;309:937-9

NICE. Tobacco: harm reduction approached to smoking. June 2013. Public health guidance PH45. 

Access the information on Patient.co.uk on Smoking – The Facts, available at 

http://www.patient.co.uk/health/smoking-the-facts

 to refresh your memory on the harmful effects of smoking. Make a note of any that you found surprising, and discuss with colleagues at the next practice clinical meeting.

Question 2

What is the estimated shortening of life cause by smoking each cigarette?

It is estimated that 11 minutes of life are lost for each cigarette smoked. There is of course some guesswork producing a figure like this. The number crunching involves working out the years of life ‘lost’ by smoking, and then dividing it by the total number of cigarettes smoked. As far as an individual smoker is concerned, the 11 minutes has no discernible meaning – half of smokers do not die of a smoking-related illness, so presumably each cigarette has no impact on their longevity. But the objective here is to produce eye-catching statistics in a form that may get through to smokers to the extent that they try to stop.

Department of Health. Healthy Lives, Healthy People. White Paper, 2010. 

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216096/dh_127424.pdf

Shaw M et al. Time for a smoke? One cigarette reduces your life by 11 minutes (letter). BMJ 2000;320:53

Read the article on MedicineNet.com available at 

http://www.medicinenet.com/script/main/art.asp?articlekey=180753.

 Consider the impact of positive 'gain-framed' and negative 'loss-framed' messages to motivate people to stop smoking. Which type of message do you think you would find most effective?

Question 3

Which of the following aids to smoking cessation is available on NHS prescription?

Healthcare professionals may recommend and prescribe nicotine replacement therapy (NRT), varenicline or bupropion as an aid to help people stop smoking, along with giving advice, encouragement and support, or referral to a Stop Smoking service.

Varenicline is licensed for smoking cessation in adults. It is a selective nicotine-receptor partial agonist, and alleviates symptoms of craving and withdrawal, and reduces the rewarding and reinforcing effects of smoking.

Nicotine patches and nicotine gum are forms of NRT, and as well as being available on prescription, can also be purchased over the counter. Although NRT contains nicotine, it does not contain any of the other 4,000 chemicals found in tobacco smoke, and in all situations is considered to be safer than smoking. There is no nicotine injection. Electronic cigarettes (e-cigarettes) are not currently regulated by the Medicines and Health products Regulatory Authority (MHRA) and therefore can be purchased in many of the same outlets where cigarettes are bought. Hypnosis and acupuncture are widely used as aids to stop smoking, but patients pay privately.

NICE PH10. Smoking cessation services, 2008. 

Question 4

Susan has now reached 60 and has recently been diagnosed with angina, which has prompted her to make a determined effort to stop her 15 cigarettes a day. She seeks your advice because she wants help, but she has taken amitriptyline for many years because of depression. Which of the following would you recommend?

Bupropion is used in some countries for depression, and although its mode of action in smoking cessation is not clear, it may involve an effect on noradrenaline and dopamine neurotransmission, and can interact with other antidepressants (especially monoamine oxidase [MAO] inhibitors). Varenicline should only be used with caution in patients with underlying psychiatric illness, including depression, which it may exacerbate. Patients need to be advised to discontinue treatment and seek medical advice promptly if they develop depressed mood or suicidal thoughts. Therefore it would be unwise to consider varenicline for Susan, who has a long history of depression. Susan smokes 15 cigarettes a day, so she probably has a degree of nicotine addiction: of the two options for NRT suggested, gum only gives a temporary dose, so a nicotine patch is probably the better choice.

British National Formulary. Nicotine dependence (May 2014)

http://www.medicinescomplete.com/mc/bnf/current/PHP3188-nicotine-dependence.htm

Nicotine addiction in Britain: A report of the Tobacco Advisory Group, Royal College of Physicians. 

https://www.rcplondon.ac.uk/publications/nicotine-addiction-britain

Click ‘NEXT’ to continue to intermediate questions or ‘EXIT” to review your results for this module

Question 5

Julie is 50 years old, and supports her family by juggling three part time jobs. She smokes 10 to 15 cigarettes a day, and knows that she should stop, but when she has tried before she has not been successful. Which of these smoking cessation strategies is the most effective?

The order in decreasing order of effectiveness is varenicline, bupropion, nicotine replacement therapy, and brief intervention: all of these are more effective than doing nothing, even though many people who have stopped smoking have done it by their own efforts. ‘Brief intervention’ helps 2.5% stop, a Number Needed to Treat (NNT) of 40. The Cochrane figures give NNTs for other strategies as: nicotine replacement: 23; bupropion: 18; varenicline: 10.

Reviews of interventions for smoking cessation can be accessed at 

http://www.phc.ox.ac.uk/research/cochrane

Review the smoking cessation services currently available to your practice patients? Could in-house services be improved? How would you make the changes required?

Question 6

‘Pack years’ is a way of expressing the total number of cigarettes a person has smoked in their lifetime, and so is a way of estimating the total amount of tobacco smoke exposure. A ‘pack’ equals 20 cigarettes. Gladys is 65. From age 17 she smoked 20 cigarettes a day, but stopped for 5 years when 28 for the duration of her pregnancy and until her children started school. Then she smoked 10 a day until her heart attack aged 57. She found she could not stop but has reduced to 3 cigarettes a day. How many ‘pack years’ has Gladys smoked?

From age 17 to 28 Gladys smoked 20 (a pack) a day, so that makes 11 pack years. From 33 to 57 she was on 10 (half a pack) a day, so that is 12 pack years (24 years at half a pack a day). From 57 to 65 (8 years) she was on 3 a day, which is 3/20 of a pack. So multiply by 8 years and that gives you 1.2 pack years. 11 + 12 + 1.2 makes 24.2 pack years.

Light smoking: Dangerous in any dose. Harvard Men’s Health Watch, May 2012

http://www.health.harvard.edu/newsletters/Harvard_Mens_Health_Watch/2012/May/light-smoking-dangerous-in-any-dose

Recording ‘pack years’ aids assessment of risk and diagnosis of COPD. Catherine Tutt and Dr Nigel Masters, 2007 

http://www.guidelinesinpractice.co.uk/jul_07_tutt_copd_jul07#.VDf72yhi-NA

Access the ‘Smoking Pack Years’ calculator at 

 How could you use this with your own patients?

Question 7

Three months ago, Doreen was discharged from hospital following a stroke. She managed to break her 10-a-day cigarette habit in hospital, but since returning home has become very anxious, and started smoking again because she finds that it ‘settles her nerves’. Which of the following is true?

Making a list of the pros and cons of smoking for the individual and their reasons to stop or continue smoking can be helpful in motivating them to attempt to give up. Stopping smoking requires motivation, and in every case there are pros and cons to stopping. Only Doreen knows her own list of pros and cons, and knowing this list assists future management. There is no level of smoking that confers zero risk on a patient after a stroke. Feelings of depression and anxiety are normal after a stroke and cannot be avoided. ‘Talking treatments’ often help, and in many areas trained post-stroke nurses undertake this role. In the longer term, an SSRI might be considered if symptoms persist, but at this stage Doreen is having a loss reaction – grieving for her lost health and abilities – so taking an SSRI may be premature. Starting to smoke again is a bad idea, whichever way you look at it. As with any prescribing decision, it is important to weigh the risks and benefits of each option. Given Doreen’s possible mental health issues, NRT is probably the best choice to help her stop smoking altogether, or at the very least, reduce her smoking further. According to the BNF, most of the warnings for NRT also apply to continued smoking, but the risk of smoking outweighs any risks of using NRT.

Primary care essentials: Stroke prevention

Royal College of Physicians. National clinical guidelines for stroke. Fourth edition. RCP 2012

http://www.rcplondon.ac.uk/sites/default/files/national-clinical-guidelines-for-stroke-fourth-edition.pdf

Referring to the article at Patient.co.uk on Smoking – The Facts, available at 

 construct your own checklist of reasons to give up smoking. Also consider cosmetic and social factors, such as its effect on complexion, tobacoo odour on clothers and hair, and the impact of the ban on smoking in public places.

Question 8

Doreen produces her list of her reasons for continuing to or stopping smoking. Her reasons to stop are the same as the reasons to stop they gave her in hospital. Her reasons to continue include: a cigarette settles her nerves when she feels anxious; she does not want to put weight on as her mobility is already not very good; her annuity insurance company offered her a favourable rate on the proviso that she continued smoking; and she would rather die of another stroke than be disabled for the rest of her life. Which of the following is a sensible strategy?

The usual response of people to being told what to do is to assume a diametrically opposite opinion. She has been truthful in drawing up her list: it is her list and so is neither silly nor open to debate. It would be unusual if Doreen were not emotionally traumatised by her stroke. However, the question of smoking is on the agenda, and even if decisions about a management plan are put ‘on hold’, this is not a reason to take the topic off the agenda. At least start to ‘strike while the iron is hot’. Insurance companies are commercial organisations whose purpose is to make a profit for shareholders. Smokers die earlier so do not draw their pensions for as long, which is how companies can offer preferential rates. Companies are also in competition with each other for your business, so looking around other companies is sensible. Where gastric banding procedures are done on the NHS, they are subject to strict criteria, and so are not in your gift. No two strokes are ever quite the same: brain tissue has been damaged so that long-term recovery depends on different parts of the brain taking over the lost function. Having had one stroke the risk of another is very much greater but it is never possible to predict whether or not it will be fatal.

Smoking cessation: tailoring your approach to the individual smoker

NICE PH45 Tobacco: harm reduction approached to smoking, 2013. 

Read the BMJ article on motivational interviewing cited below. Think how these strategies could be incorporated into you own practice, and what the implications would be in terms of costs and benefits.

Rollnick S, Butler C, Kinnersley P, et al. Motivational interviewing. BMJ 2010;340:c1900 

Question 9

The next time you see Doreen she shows you an electronic cigarette she has bought. She appears delighted with her purchase, and asks you for further information about whether you think it is a good idea. Which of the following is true?

Some people smoke because they like the look and the feel of the cigarette in their fingers. This is part of the appeal of the electronic cigarette, but it is also a drawback as it perpetuates the sensation of holding a cigarette, so users will not have truly broken their habit. While it is likely to be true that electronic cigarettes are safer than smoking tobacco, so far proof is lacking. However with 1.3 million users in the UK, it should not be too long before proof is available. A2 is false – legislation has yet to catch up with flourishing electronic cigarette sales, and there is currently no legal ban on ‘vaping’ in public places. The nicotine is the same as the nicotine obtained from cigarettes. However, the vapour (they do not emit smoke), although not entirely free of toxic substances, does not contain the other 4,000 chemicals found in tobacco smoke, and these are the ones that cause the harm. From 2016 electronic cigarettes will be regulated as a drug by the MHRA, just as they already are in a number of countries, but there are no plans so far to make them available on prescription in the UK.

e-cigarettes: a Practice Nurse guide Mandy Galloway

Smoking cessation – Tailoring your approach to the individual smoker

Action on Smoking and Health (ASH). Briefing: Electronic cigarettes, June 2014. 

http://www.ash.org.uk/files/documents/ASH_715.pdf

Access the BMA briefing paper on e-cigarettes, available at 

http://www.bma.org.uk/working-for-change/improving-and-protecting-health/tobacco/e-cigarettes.

 Discuss with colleagues how you might respond to patients who ask advice about using e-cigarettes as an aid to smoking cessation.

Smoking cessation

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