This talk is mostly aimed at staff in secondary care and will be relevant for doctors, pharmacists, nurses, (including ward nurses, theatre nurses, outpatient nurses, nurse specialists in all areas) allied health professionals and healthcare assistants.
These questions are shown again at the end of the talk and the correct answers, with explanations, are shown in the speakers notes.
This subject is particularly relevant in view of recent guidelines from the National Institute of Clinical Excellence (NICE) which states that all health professionals should be able to give brief, individual advice about stopping smoking.
The aims of this presentation are to cover the core knowledge, skills and attitudes needed by all healthcare professional to deliver good, brief, individual advice on stopping smoking. There are additional slides at the end of the presentation to help health professionals who are able to prescribe.
This talk covers briefly the effects of smoking on health, the implications of addiction to nicotine - the main reason that most smokers smoke - plus smoking cessation strategies that are proven to help people to stop successfully. Staff should also be aware of local services available, and these may vary from area to area.
Smoking causes a death every 15 mins in the UK – 4 people per hour. Directly responsible admissions per day – around a quarter of acute medical patients are admitted due to smoking related health problems.
The majority - two thirds - of deaths due to smoking are from lung cancer, heart disease and COPD. These conditions also account for a high proportion of emergency hospital admissions.
Key Message: Smokers die almost 10 years earlier than non-smokers. The estimated gain in life expectancy from quitting at given ages is clinically significant at all ages. Note almost three years of life gained in female smokers who quit at 65, as well as improvements in morbidity – for example fewer hospital admissions with COPD for patients who stop smoking in their 60’s. If the pension age goes up to 70, then most male smokers will die before they collect their pension. ________________ Taylor DH, Jr., Hasselblad V, Henley SJ, Thun MJ, Sloan FA. Benefits of smoking cessation for longevity. Am J Public Health 2002;92:990-6
Key Messages : Withdrawal from nicotine usually leads to nicotine cravings. These cravings can be a major barrier to successfully giving up smoking. Nicotine in cigarettes is not harmful by itself, but it is the inhalation of toxic gases and chemicals that causes the health effects. Slide 43 - The cigarette - “a dirty syringe” Objective : Nicotine drives the smoking habit. Confirm that smoking is a vicious circle
Slide 42 - Components of the cigarette - “a dirty syringe” Objective : Tobacco contains many gases, chemicals and metals which are harmful to health. Confirm that people smoke to get nicotine, but it is the tar and gases from smoking, that can cause the harm Nicotine is the substance in tobacco that causes dependence in smokers. Tobacco smoke contains over 4,000 compounds some of which are toxic, mutagenic and/or carcinogenic. When tobacco leaves are burnt, a number of substances are released, including nicotine, however, it is the tar and gases from smoking that can cause the harm.
Despite all of the smoking cessation interventions over the past few years, smoking is still a common problem, particularly in people living in deprived areas, and in people coming to hospital with health problems. Most smokers do actually want to quit, so health professionals are 'pushing at an open door' when advising patients to stop smoking. However, stopping smoking without support is difficult - many patients will have tried and failed, so it is important to be positive about the chances of success in the future.
Slide 49 - The role of the health care professional - what prompted an attempt to stop smoking? Objective : To demonstrate the important role health care professionals play in helping and encouraging smokers to quit Quitting smoking is more of a process carried out over time, rather than a one off event. This graph illustrates all the elements that play an important role in increasing a smokers’ motivation to quit, and in triggering a cessation attempt. It demonstrates the important role of the health care professional in helping smokers quit. Offering advice may act as a trigger to stopping smoking and as a means of support, when making a quit attempt (see reference 1). Reference : 1. West R. Getting Serious About Stopping Smoking. 1997: A Report for No Smoking Day
This slide shows the percentage of people still not smoking 6 months after they tried to stop using various methods. Only 2% stop with willpower alone, but this figure doubles with brief advice from a health professional, even without using group support or medication. This might not seem much of an improvement, but when you think that there are 12 million smokers in the UK, raising the success rate from 2% to 4% can make a big difference to actual numbers quitting. The best results - around 1 in 6 patients still not smoking at 6 months - are with medication plus intensive support from local stop smoking services.
Slide 38 - Most smokers need help to quit. Methods used to stop smoking Objective : Demonstrate that whilst smokers need help to quit, most smokers still use willpower alone While most smokers want to quit, very few succeed. This makes sense as the majority of smokers trying to quit, use willpower alone. 1 Those who used NRT had a greater chance of successfully quitting than those who did not. 2 Studies show that the use of nicotine replacement therapy can double a smoker’s chances of successfully quitting. 3 It’s important to note that ‘herbal cigarettes’, although they do not contain nicotine, still contain carcinogens and carbon monoxide, and are not a ‘safe alternative’. References : 1. Shiffman S. Critical review of the current status of smoking cessation in the USA. Tobacco Control 1995; 4 (suppl 2): S3-S24 2. West R. Getting serious about stopping smoking. A report for No Smoking Day 1997 3. Shiffman S. Public health benefits of over-the-counter nicotine medications. Tobacco Control 1997; 6: 306-310
This slide summarises the core skills that health professionals should have in order to deliver good smoking cessation advice to as many smokers as possible.
The 5 A’s framework can be used as an aide memoire. The A’s above the line can be carried out by all health care professionals and form the basis for ‘brief intervention’. Reference: Smoking Cessation Guidelines for Health Professionals : an update Thorax, 2000, Vol. 55; 987-999
At this point, you could discuss how smoking status is recorded in your patients, and whether health care professionals in the group have access to this information.
These are examples of some of the things that we might say to patients. It is important to stress that giving up smoking is the most important thing the patient can do for their health, they will feel the benefits quickly and that that there is support available that won’t cost them a lot of money. It is important that patients appreciate the effects of continued smoking in terms of their own disease and their medication.
Two simple questions to identify the ‘happy smokers’ – around 30% of smokers who have no intentions to quit - as opposed to those who want to quit – try and put a time frame on it i.e. ‘ Do you want to give up within the next few weeks?’
Smoking is often associated with relaxation, but the feeling of ‘stress relief’ is often situational, or related to relief of withdrawal symptoms. Smokers do put on weight when they stop – an average of 4kg – but this can be halved by using nicotine replacement therapy or bupropion. Switching to roll ups (or light cigarettes) is not a healthy option, as the amount of tar and carbon monoxide inhaled does not reduce. Many patients find their cough gets worse after they quit smoking, as the small hairs (cilia) in the windpipe grow back and start bringing all the ‘gunk’ back to the surface again. This usually settles after 4-6 weeks. Starting smoking again simply kills all the cilia and puts the process back to square one. Other misconceptions include the fact that women who smoke will have easier deliveries (in fact their babies are smaller, less healthy, more likely to be born prematurely and more likely to spend time on special care baby units).
All health professionals can offer behavioural support. This takes a little more time than brief advice but is effective on the wards, in outpatients etc. Important that prescribers prescribe! – but doctors should also be prepared to deliver simple behavioural support. Smoking triggers may be things like trips to the pub, stressful situations, after meals, with certain friends – ask the group to discuss different smoking triggers.
Referral processes vary and unfortunately some hospitals do not have a dedicated inpatient smoking cessation counsellor, but patients can be referred to community teams for follow up.
Smokers smoke not out of choice but because they are addicted to nicotine. People who have smoking-related illnesses may blame themselves for their conditions – it is important to be clear that you do not perceive their condition to be ‘self-inflicted’ or ‘all their own fault’ as nicotine addiction is extremely powerful and difficult to overcome.
This concludes the first section of the talk, which applies to all healthcare professionals. We now move on to cover specialty specific health effects and additional competencies for prescribers.
Attitudes to smoking cessation in cancer patients are often nihilistic, but smoking cessation even at this stage can improve quantity and quality of life, particularly in those undergoing treatment. Median survival in this study 18 vs 13.6 for quitters/abstainers versus continued smokers. 5 year survival 8.9 vs 4% is quitters/abstainers JNCI1997,89(23):1782-8. SPLC after Rx for SCLC : relative to general population – the risk is increased 3.5 times. If you get RT – it is 13 times versus 7 times in non RT patients. Higher in continued smoking – combined with RT – RR of 21. 20.5% had RT interruptions of median 5 days. Continuing smokers did not have more treatment breaks, but those who CS and had tx break had poorest overall survival, median at 13.4 months.
Non-smokers were never plus former (>2 year quit); current include recent (within one year) and true current smokers. No difference between smokers and non-smokers in Stage III lung cancer.
Tammemagi – effect was not explained by sociodemographic or environmental exposures, adverse symptoms, histology, stage co-morbidity or treatment. 18% never smokers, 58% former smokers, 24% current smokers At first follow up: 95% were abstinent Current smokers – 70% had quit at follow up but 30% continued to smoke persistently through treatment. No dose trends noted. Components worse were appetite, fatigue, cough, shortness of breath, lung cancer symptoms, illness affecting normal activities and overall score.
Klareskog L, Padyukov L, Alfredsson L. Smoking as a trigger for inflammatory rheumatic diseases. Current Opinion in Rheumatology 19, 49-54. January 2007. Smoking Intensity, Duration, and Cessation, and the Risk of Rheumatoid Arthritis in Women. The American Journal of Medicine, Volume 119, Issue 6, Pages 503.e1-503.e9 K. Costenbader, D. Feskanich, L. Mandl, E. Karlson
In paediatric practice, attitudes towards parents and carers who smoke can be variable – studies suggest that parents expect to be advised to quit smoking for the sake of their child’s health, but that this advice is not often given. References: Jarvis MJ et al. Children’s exposure to passive smoking in England since the 1980s: cotinine evidence from population surveys. BMJ 2000; 321: 343-345 Strachan, DP and Cook, DG. Parental smoking and lower respiratory illness in infancy and early childhood. Thorax 1997; 52: 905-914. Respiratory health effects of passive smoking. EPA/600/6-90/006F United States Environmental Protection Agency, 1992. International Consultation on ETS and Child Health. WHO/NCD/TFI/99.10, World Health Organization, 1999. Smoking status of cohabiting adults should be asked about in all children admitted to hospital – parents expect to be asked – and smoking cessation advice given where necessary, emphasising the above effects on children’s health.
Most women are aware of the risks of smoking during pregnancy, and many do manage to give up whilst pregnant, although most start again after delivery. Nicotine replacement therapy – short-acting, such as gum – can be used during pregnancy if the woman has tried and failed to give up without. A trial of NRT in pregnancy is ongoing. It is important for prospective fathers to quit smoking too because of passive smoke exposure to both foetus and newborns. Much of the information above is from the BMA report on smoking and reproduction - http://www.bma.org.uk/ap.nsf/Content/SmokingReproductiveLife
Smoking can be overlooked by staff and carers working with people with mental health difficulties, but they have equal rights to help with smoking cessation. Reasons for higher smoking rates may include socio-economic deprivation, smoking as a coping mechanism or a form of self-medication, the environment and culture of mental health services - those living in psychiatric institutions have higher rates of smoking than those with similar illnesses living at home. Suggestions as to why so many patients in psychiatric hospitals smoke include boredom and lack of recreational activities, smoking as a social activity, the use of cigarettes as incentives, staff smoking and lack of smoking policies. To continue to make exemptions for people experiencing mental health difficulties is discriminatory and will continue the risk of smoking related disease in this community. Further information from a useful ASH fact sheet - www.ash.org.uk/html/factsheets/html/fact15.html
Slide 33 - Benefits of stopping smoking Objective : To gain agreement of the health benefits of stopping smoking using lung function as an example Air flow obstruction is the physiological consequence of diseases that narrow the airway. In epidemiological studies, airflow obstruction is usually defined as a ‘forced expiratory volume in 1 second’ (FEV 1 ). In nearly every population studied world-wide, cigarette smoking is the dominant factor for the prevalence of airway obstruction 1 Numerous studies have documented the correlation between cigarette smoking and the decline in lung function 1 This model shown depicts the decline in (FEV 1 ) among smokers with varying degrees of susceptibility to cigarettes and the benefits of quitting. The decline in lung function is steeper in smokers than non smokers, resulting in progressive lung damage, leading to chronic obstructive pulmonary disease (COPD) symptoms and death 1 When a smoker quits, the rate of decline slows and with sustained abstinence, the rate of decline in former smokers returns to that of someone who has never smoked. This emphasises the importance of smoking cessation and the fact that it is never too late to quit 1 Reference : 1. Orleans CT, Slade J eds. Nicotine addiction: principles and management. New York: Oxford University Press, 1993;(6):118-119
Former smokers: those who quit 4 or more weeks previously
Now we move on to cover additional competencies for people who are able to prescribe pharmacotherapy to help with a quit attempt.
Can use more than one form of NRT – cf. insulin basal bolus regime – a long acting patch for baseline nicotine, plus a short acting product for ‘breakthrough’ cravings. Most patients do not use (or are not prescribed) nearly enough nicotine.
Many local smoking cessation services will not support patients cutting down rather than making a formal quit attempt. This indication justifies the prescription of NRT for hospital inpatients who are forced to stop whilst in hospital – especially on a smoke-free site – but may not be ready to make a formal quit attempt.
The cigarette is a very efficient nicotine delivery device and takes nicotine to the brain in just 10 seconds – none of the nicotine replacement products can compete with this, but the nasal spray is the fastest acting, and useful for heavy smokers if they can cope with the side effects of watering eyes and nasal irritation.
Nicotine is not harmful Short acting products include gum, lozenges and the inhalator. No trials in pregnancy – use short acting products if cannot quit without.
Bupropion is generally an extremely safe drug, with fewer side effects than the SSRI’s or amitryptilline. Bad publicity from the tabloid press has made patients - and doctors – cautious. Doctors who are not experienced with bupropion may refuse to prescribe it to patients, or may believe it to be contraindicated eg. in diabetes, depression or hypertension – when it is not.
True False. Lung cancer accounts for 25% of smoking related deaths, COPD 20% False – 1,000 UK admissions per DAY are directly attributable to smoking. True
False – only 1-2% of motivated smokers manage to quit per year with no help True False – nicotine is relatively safe; tar, carbon monoxide and other chemicals cause the harm. True
False – over two thirds of smokers would like to quit smoking False – the most effective way is intensive behavioural support combined with pharmacotherapy. True False – and in fact may be more harmful as roll ups may not have filters.
2. is correct
True – until recently, cutting down was not advised but new data show that using NRT to cut down can lead to successful quit attempts False – smoking relieves nicotine withdrawal rather than stress, and there is no evidence that smokers are more relaxed! True True – can halve the amount of weight gained
False – most people smoke because they are addicted to nicotine. False Discuss! – may differ by specialty and area True
True False – all nicotine replacement therapies are equally effective if used correctly False – they are available on prescription which means that people who do not pay for their prescriptions can get free NRT True
True False – no conclusive data False – good trial data to show it’s effectiveness in this group True – although this should normally done by a specialist smoking cessation clinic
Elin Roddy and David Ross British Thoracic Society Tobacco Committee April 2007
Callum C. The UK Smoking Epidemic: Deaths in 1995. Health Education Authority 1998 p29 Deaths caused by smoking-related diseases
Taylor et al, AM J Public Health 2002;92:990-6 Benefits of Quitting Smoking Men Women Life expectancy Extra years compared to smokers Life expectancy Extra years compared to smokers Smoked until death 69.3 73.8 Never smoked 78.2 8.9 81.2 7.4 Quit at age 35 76.2 6.9 79.9 6.1 Quit at age 45 74.9 5.6 79.4 5.6 Quit at age 55 72.7 3.4 78.0 4.2 Quit at age 65 70.7 1.4 76.5 2.7
Addiction Disease and Death Carcinogens Toxic gases 30% of all cancers 66% of all COPD 13% of all Vascular disease Cravings Smoking Nicotine A Vicious Circle Peto R et al. Mortality from smoking in developed countries 1950 - 2000: Indirect estimates from National Vital Statistics. Oxford University Press 1994
Nicotine Carbon Monoxide Tar Acetone Cadmium Arsenic Cigarette Smoke Contains more than 4,000 chemicals including over 40 known carcinogens No Smoking Day, UK. No Smoking Day Fact Sheet 4 1997 Hydrogen Cyanide
Why are smoking cessation interventions important?
Smoking remains common
28% adults smoke in the UK
Prevalence essentially static over last 10 years
Increasing in young women
Prevalence up to 70% in deprived areas
Smokers would like to stop
70% say that they would like to stop smoking
Few smokers can stop without help
Each year only 1% of smokers stop with willpower alone
General Household Survey 2000
% Base: 672 smokers currently trying to stop or made attempt to stop in past year. West R. Getting Serious About Stopping Smoking. A Report for No Smoking Day 1997
89% of lung cancer deaths in men and 74% in women are attributable to smoking
Over 80% of all COPD deaths are attributable to smoking
Smoking increases the risk of pneumonia
Smoking increases rate of exacerbations and decline of FEV1 in asthmatics
Continued smoking reduces the effectiveness of inhaled corticosteroids in asthma
Children who smoke are three times more likely to have time off school
Peto et al BMJ 2000
1. Fletcher CM, Peto R. The natural history of chronic airflow obstruction. BMJ 1977; 1(6077): 1645-1648 100 75 50 25 0 25 50 75 Never smoked or not susceptible to smoke Smoked regularly and susceptible to its effects Stopped at 45 Stopped at 65 Disability Death Age (in years) FEV 1 (% of value at age 25)