Elin Roddy and David Ross


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  • 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[1], 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

    1. 1. Elin Roddy and David Ross British Thoracic Society Tobacco Committee April 2007
    2. 2. Aims and Objectives <ul><li>To ensure that all NHS staff directly involved with patient care meet a basic set of core competencies to enable them to identify and support smokers who want to stop smoking </li></ul>
    3. 3. Pre-talk questions – true or false? <ul><li>Smoking is the commonest preventable cause of death in the developed world </li></ul><ul><li>COPD is the commonest cause of death in smokers </li></ul><ul><li>Smokers live on average 8 years less than non-smokers </li></ul><ul><li>Cutting down the number of cigarettes smoked can be useful </li></ul>
    4. 4. Pre-talk questions – true or false? <ul><li>Most smokers smoke out of choice </li></ul><ul><li>25% of smokers want to quit smoking </li></ul><ul><li>Nicotine withdrawal peaks at 3-5 days </li></ul><ul><li>Using nicotine replacement therapy doubles the chances of quitting </li></ul><ul><li>Bupropion should only be used in hospital patients </li></ul>
    5. 5. Where this fits – NICE guidance <ul><li>Brief chats between people who smoke and health professionals about stopping smoking are both effective and cost effective in helping people to stop smoking. </li></ul><ul><li>All health professionals should advise all smokers to stop smoking, not just those who are already ill. </li></ul><ul><li>Advice should be sensitive to individual needs. </li></ul>NICE public health guidance: focus on smoking cessation and physical activity http://www.nice.org.uk/page.aspx?o=300139
    6. 6. Aims and Objectives <ul><li>Knowledge </li></ul><ul><li>Skills </li></ul><ul><li>Attitudes </li></ul><ul><li>Additional competencies for prescribers </li></ul>
    7. 7. Knowledge <ul><li>Effects of smoking on health </li></ul><ul><li>Implications of addiction to nicotine </li></ul><ul><li>Cessation strategies available to help smokers to quit </li></ul><ul><li>Local smoking cessation services available </li></ul>
    8. 8. Effects of smoking on health <ul><li>Deaths per year: </li></ul><ul><li>120,000 </li></ul><ul><li>Hospital admissions per year: </li></ul><ul><li>365,000 </li></ul><ul><li>GP consultations per year: </li></ul><ul><li>1.2 million </li></ul>
    9. 9. Callum C. The UK Smoking Epidemic: Deaths in 1995. Health Education Authority 1998 p29 Deaths caused by smoking-related diseases
    10. 10. 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
    11. 11. 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
    12. 12. 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
    13. 13. Why are smoking cessation interventions important? <ul><li>Smoking remains common </li></ul><ul><ul><li>28% adults smoke in the UK </li></ul></ul><ul><ul><li>Prevalence essentially static over last 10 years </li></ul></ul><ul><ul><li>Increasing in young women </li></ul></ul><ul><ul><li>Prevalence up to 70% in deprived areas </li></ul></ul><ul><li>Smokers would like to stop </li></ul><ul><ul><li>70% say that they would like to stop smoking </li></ul></ul><ul><li>Few smokers can stop without help </li></ul><ul><ul><li>Each year only 1% of smokers stop with willpower alone </li></ul></ul>General Household Survey 2000
    14. 14. % 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
    15. 15. Smoking Cessation strategies <ul><li>Willpower </li></ul><ul><li>Alternative therapies </li></ul><ul><li>Brief advice from a health professional </li></ul><ul><li>Brief advice plus nicotine replacement therapy or bupropion </li></ul><ul><li>Behavioural support in small groups or individually </li></ul><ul><li>Behavioural support in small groups or individually plus nicotine replacement therapy or bupropion </li></ul>
    16. 16. Effectiveness of smoking cessation* * No reliable data for success with alternative therapies
    17. 17. % West R. Getting serious about stopping smoking. A report for No Smoking Day 1997
    18. 18. Skills <ul><li>Identifying all smokers </li></ul><ul><li>Delivering brief opportunistic smoking cessation advice to all smokers </li></ul><ul><li>Assessment of patient’s commitment to quit </li></ul><ul><li>Referring to local specialist smoking cessation services </li></ul>
    19. 19. <ul><ul><li>ASK smoking status </li></ul></ul><ul><ul><li>ADVISE all smokers to quit </li></ul></ul><ul><ul><li>ASSESS willingness to quit </li></ul></ul><ul><ul><li>ASSIST motivated smokers to quit </li></ul></ul><ul><ul><li>ARRANGE follow-up </li></ul></ul>What we should be doing – The 5 As
    20. 20. 1. Ask smoking status <ul><li>All patients should be asked their smoking status – ‘Current, Ex- or Never Smoker’ </li></ul><ul><li>This should be clearly documented in GP notes, Medical notes, Nursing notes or AHP notes </li></ul><ul><li>Consider the use of a proforma or a stamp </li></ul>
    21. 21. 2. Advise – Brief, Personalised <ul><li>‘ The best thing you can do for your health is to stop smoking, and I advise you to stop as soon as possible.’ </li></ul><ul><li>‘ You will start to feel the benefits of quitting smoking very quickly.’ </li></ul><ul><li>‘ There are things available free of charge or on prescription to help you give up.’ </li></ul><ul><li>‘ Your asthma /angina/ circulation will certainly get worse if you carry on smoking.’ </li></ul><ul><li>‘ Your inhalers will not work as well if you continue to smoke.’ </li></ul><ul><li>‘ These breathing tests/X-rays already show some smoking related damage.’ </li></ul>
    22. 22. 3. ASSESS <ul><li>Assess willingness to quit </li></ul><ul><ul><li>‘ How do you feel about your smoking?’ </li></ul></ul><ul><ul><li>‘ Have you thought about giving up?’ </li></ul></ul><ul><li>If unwilling If willing </li></ul><ul><li>give information give or refer for assistance </li></ul>
    23. 23. 4. ASSIST <ul><li>Help smokers to understand their smoking behaviour </li></ul><ul><li>Give ‘common sense’ behavioural support </li></ul><ul><li>Prescribe nicotine replacement therapy or bupropion (this is covered later under ‘Additional Competencies for Prescribers’) </li></ul>
    24. 24. Understanding smoking behaviour <ul><li>Health effects of nicotine/ smoke </li></ul><ul><li>Withdrawal syndrome </li></ul><ul><li>Address misconceptions around quitting: </li></ul><ul><li>‘ Smoking helps me deal with stress’ </li></ul><ul><li>‘ I’ll put on weight’ </li></ul><ul><li>‘ I’ve switched to roll ups’ </li></ul><ul><li>‘ My chest gets worse when I stop’ </li></ul>
    25. 25. ‘ Common sense’ behavioural support <ul><li>Set a QUIT DATE, tell friends and colleagues </li></ul><ul><li>Identify and avoid smoking triggers </li></ul><ul><li>Review past quit attempts </li></ul><ul><li>Plan ahead for difficult times, relapses </li></ul>
    26. 26. 5. ARRANGE follow up <ul><li>All patients should have access to a local specialist smoking cessation service </li></ul><ul><li>Arrange follow-up with this service </li></ul><ul><li>Soon after quit date (ideally within 1 week) </li></ul><ul><li>Use exhaled carbon monoxide to validate </li></ul>
    27. 27. Attitudes <ul><li>Non-judgemental approach to smokers </li></ul><ul><li>Acknowledge role of addiction and importance of support </li></ul><ul><li>Most smokers do not choose to smoke but do so because they are addicted to nicotine </li></ul><ul><li>Most smokers will not be able to give up without support </li></ul><ul><li>Smokers have equal rights to best available treatments </li></ul>
    28. 28. Summary <ul><li>Health care professionals should understand that most smokers smoke because of addiction to nicotine and not out of choice </li></ul><ul><li>Most smokers would like to quit , but the majority will not do so without help </li></ul><ul><li>All health care professionals should ask patients whether they smoke and offer brief, personalised advice to stop smoking to all smokers, not just those who are unwell </li></ul><ul><li>Health care professionals should know where to refer patients for extra support </li></ul>
    29. 29. Action Plan <ul><li>Ask your group – where and how do they see themselves giving brief stop smoking advice? </li></ul><ul><li>And remember, in two minutes: </li></ul><ul><li>An outpatient care assistant could advise a patient with COPD about stopping smoking and where to find help </li></ul><ul><li>A junior doctor on a ward round could advise a patient with angina, and prescribe drug treatment </li></ul><ul><li>A physiotherapist doing a stair assessment with a stroke patient could give brief advice about stopping smoking and the ways to do it </li></ul><ul><li>A pre-op nurse could reduce post operative complications by delivering brief advice to a patient coming for hernia repair, and giving information on local stop smoking support available </li></ul>
    30. 30. Useful References <ul><li>NICE public health guidance: focus on smoking cessation and physical activity http://www.nice.org.uk/page.aspx?o=300139 </li></ul><ul><li>A guide to effective smoking cessation interventions for the health care system. Thorax 1998;53:suppl 5(1):S1-19. </li></ul><ul><li>‘ Smoking Kills’ – A White Paper on Tobacco, 1998 </li></ul><ul><li>Nicotine Addiction in Britain, RCP 2000 </li></ul><ul><li>ABC of Smoking Cessation, BMJ 2004 </li></ul>
    31. 31. Additional slides – specialty specific health effects and additional competencies for prescribers
    32. 32. Effects of smoking on health -Cardiovascular <ul><li>Smokers are twice as likely as non-smokers to die from ischaemic heart disease </li></ul><ul><li>Smokers are six times more likely to die from an aortic aneurysm </li></ul><ul><li>People who have never smoked have a 30% greater risk of ischaemic heart disease if they live with a smoker </li></ul><ul><li>Smokers are over three times as likely as non-smokers to have a stroke </li></ul><ul><li>A meta-analysis of smoking cessation after a heart attack shows that those who quit smoking are less likely to die* </li></ul>*Wilson K Arch Intern Med 2000;160:934-944
    33. 33. Effects of smoking on health - Gastroenterology <ul><li>Smoking is a risk factor for cancer of the pancreas and oesophagus </li></ul><ul><li>Reflux disease has a higher incidence and is more severe in people who smoke </li></ul>
    34. 34. Effects of smoking on health – Oncology: Small Cell Chemotherapy/Radiotherapy and Outcome <ul><li>Videtic et al, JCO April 2003 </li></ul><ul><li>Retrospective study, 215 Pts. Limited Stage </li></ul><ul><li>42% continued to smoke </li></ul><ul><li>58% non-smoking during CHT/RT </li></ul><ul><li>Median survival: 18 vs 13.6 months </li></ul><ul><li>5-yr.: 8.9% vs 4% </li></ul>Videtic GMM, et al. JCO 21(8):1544-49, 2003.
    35. 35. Smoking Status during Radiation Therapy <ul><li>237 patients, retrospective review of smoking hx, NSCLC </li></ul><ul><li>Current smokers had shorter survival </li></ul><ul><li>Stage I/II: smokers had 2-yr survival 41% with 13.7 months median survival compared to 56% with 27.9 months in non-smokers. </li></ul>Fox, et al. Lung Cancer 2004
    36. 36. QOL and Survival in Lung Cancer <ul><li>Current smoking is predictor of shortened lung cancer survival* </li></ul><ul><li>‘ it may be mediated by biologic effects’ </li></ul><ul><li>Graces et al: Persistent smoking negatively impacted QOL scores </li></ul>*Tammemagi, CHEST January 2004
    37. 37. Effects of smoking on health - Rheumatology <ul><li>Smokers are more likely to get rheumatoid arthritis and it is more likely to be severe </li></ul><ul><li>Smoking significantly increases the vascular risk in patients with connective tissue diseases </li></ul><ul><li>Smoking exacerbates Raynaud’s disease </li></ul>
    38. 38. Effects of smoking on health - Paediatrics <ul><li>Almost half of children in UK exposed to smoke at home </li></ul><ul><li>17,000 children admitted to hospital each year with effects of passive smoke </li></ul><ul><li>70% increase in respiratory tract infections </li></ul><ul><li>Increase in incidence and severity of asthma </li></ul><ul><li>Increase in middle ear infections </li></ul><ul><li>Increased time off school </li></ul><ul><li>Children with parents who smoke are more likely to become smokers themselves </li></ul>
    39. 39. Effects of smoking on health - Pregnancy <ul><li>Problems conceiving 1.8 times more likely </li></ul><ul><li>Double the risk of miscarriage or ectopic pregnancy </li></ul><ul><li>Lower birthweight babies </li></ul><ul><li>Two fold risk in pre-term labour </li></ul><ul><li>Increased risk of cot death </li></ul><ul><li>May lead to inadequate breast milk </li></ul><ul><li>However - almost all of women who smoke before pregnancy do manage to stop once they become pregnant </li></ul>
    40. 40. Effects of smoking on health - Psychiatry <ul><li>Studies on people with mental illness living in the community show high smoking rates - 70% in people with schizophrenia, 56% with depression (vs. 28% of population) </li></ul><ul><li>People with severe mental illness tend to smoke more cigarettes per day and have a high morbidity and mortality from cardiovascular and respiratory disease </li></ul><ul><li>However, mental health problems do not undermine the ability to stop smoking. </li></ul><ul><li>Stopping smoking does not appear to exacerbate psychotic symptoms and that experience of depression does not affect quit rates. </li></ul><ul><li>Patients with mental health problems need equality of access to smoking cessation support. </li></ul>
    41. 41. Effects of smoking on health - Respiratory <ul><li>89% of lung cancer deaths in men and 74% in women are attributable to smoking </li></ul><ul><li>Over 80% of all COPD deaths are attributable to smoking </li></ul><ul><li>Smoking increases the risk of pneumonia </li></ul><ul><li>Smoking increases rate of exacerbations and decline of FEV1 in asthmatics </li></ul><ul><li>Continued smoking reduces the effectiveness of inhaled corticosteroids in asthma </li></ul><ul><li>Children who smoke are three times more likely to have time off school </li></ul>Peto et al BMJ 2000
    42. 42. 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)
    43. 43. Effects of smoking on health - Surgery <ul><li>Smoking increases peri-operative mortality and morbidity </li></ul><ul><li>Smoking cessation is most effective if done at least six weeks prior to surgery </li></ul><ul><li>Smoking decreases wound healing </li></ul><ul><li>RCT of smoking cessation prior to hip surgery reduced complications from 52% to 18%* </li></ul>*Moller AM et al, Lancet 2002,359;114-7
    44. 44. Breast Surgery and Smoking <ul><li>Current smokers have increased risk of: </li></ul><ul><li>Mastectomy flap necrosis </li></ul><ul><li>Higher donor-site complications </li></ul><ul><ul><li>Higher rate of abdominal flap necrosis </li></ul></ul><ul><ul><li>Higher rate of abdominal hernia </li></ul></ul><ul><li>Higher overall complication rate </li></ul>Chang, Plast Reconstr Surg 2000,105:2374
    45. 45. Additional skills for prescribers <ul><li>Knowledge of indications for and side-effects of nicotine replacement therapy and bupropion </li></ul><ul><li>Skills in prescribing the above treatments to support a quit attempt </li></ul>
    46. 46. Indications for NRT <ul><li>Use in all smokers who have had, or anticipate having, problems with nicotine cravings during a quit attempt </li></ul><ul><li>Adjunct, not alternative, to behavioural support </li></ul><ul><li>Reduces the symptoms of nicotine withdrawal </li></ul><ul><li>Provides a coping mechanism </li></ul><ul><li>May make cigarettes less rewarding to smoke </li></ul><ul><li>Doubles chance of successful quit attempt </li></ul>
    47. 47. Prescribing NRT <ul><li>Available on NHS prescription (which is cheaper than buying over the counter) </li></ul><ul><li>Should be available on formulary in all hospitals </li></ul><ul><li>Use in those who smoke >10 cigarettes per day and have had, or anticipate having, problems with cravings </li></ul><ul><li>Patch - use 21mg/24h patch if morning cravings a problem, otherwise use 15mg/16h plus short-acting product for cravings </li></ul><ul><li>No form of NRT can mimic a cigarette </li></ul>
    48. 48. Cut Down Then Stop (CDTS) <ul><li>New indication for NRT </li></ul><ul><li>6 studies to date </li></ul><ul><li>Using NRT to reduce number of cigarettes by 50% leads to long-term cessation </li></ul><ul><li>Nicorette gum and inhalator now licensed for this indication </li></ul><ul><li>Useful for eg. smoke-free hospitals, where patients may not want to quit but need to reduce number of cigarettes smoked </li></ul>
    49. 49. Speed of nicotine delivery
    50. 50. NRT - products available How to use Side effects Patch <ul><ul><li>Apply one 21mg or 16mg patch daily </li></ul></ul><ul><ul><li>Clean, unbroken skin </li></ul></ul><ul><ul><li>Use different site next day </li></ul></ul><ul><ul><li>Local skin rash </li></ul></ul><ul><ul><li>Insomnia (24 hour patch) </li></ul></ul>Gum <ul><ul><li>Use as required </li></ul></ul><ul><ul><li>Chew until tastes strong </li></ul></ul><ul><ul><li>Rest between gum & cheek </li></ul></ul><ul><ul><li>Chew again when taste fades </li></ul></ul><ul><ul><li>Sore throat / mouth </li></ul></ul><ul><ul><li>Indigestion </li></ul></ul>Lozenge <ul><ul><li>Use as required </li></ul></ul><ul><ul><li>Suck until tastes strong </li></ul></ul><ul><ul><li>Rest between gum & cheek </li></ul></ul><ul><ul><li>Suck again when taste fades </li></ul></ul><ul><ul><li>Sore throat / mouth </li></ul></ul><ul><ul><li>Indigestion </li></ul></ul>Inhalator <ul><ul><li>Use as required </li></ul></ul><ul><ul><li>Insert 10mg cartridge in holder </li></ul></ul><ul><ul><li>Inhale as needed </li></ul></ul><ul><ul><li>Cartridge lasts 20-30 mins </li></ul></ul><ul><ul><li>Max 12/day </li></ul></ul><ul><ul><li>Sore throat / mouth </li></ul></ul><ul><ul><li>Indigestion </li></ul></ul>Nasal Spray <ul><ul><li>Use as required </li></ul></ul><ul><ul><li>One 500mcg spray per nostril </li></ul></ul><ul><ul><li>Max. every 30 minutes </li></ul></ul><ul><ul><li>Maximum 64 sprays/day </li></ul></ul><ul><ul><li>Nasal irritation </li></ul></ul><ul><ul><li>Watery eyes </li></ul></ul>
    51. 51. Cautions for NRT <ul><li>Alternative to NRT = Smoking </li></ul><ul><li>Care in acute cardiovascular events - short acting products </li></ul><ul><li>Safe in stable cardiovascular disease, peripheral vascular disease </li></ul><ul><li>No data yet in pregnancy – if cannot quit without, then use short acting preparation </li></ul><ul><li>Cautioned in patients on clozapine, olanzapine </li></ul><ul><li>But remember - most failed quitters do not use enough nicotine </li></ul>
    52. 52. Indications for bupropion <ul><li>Smokers who are motivated to quit and have used NRT unsuccessfully, or who cannot use NRT </li></ul><ul><li>Generally used as a second line agent </li></ul><ul><li>As effective as NRT ie. doubles chances of quitting successfully </li></ul><ul><li>Very safe despite adverse publicity (less likely to cause fits than e.g. amitryptiline) </li></ul>
    53. 53. Dose regimen for bupropion Roddy, E.L. in ‘The ABC of Smoking Cessation’. BMJ 2004
    54. 54. Side effects of bupropion <ul><ul><li>Insomnia </li></ul></ul><ul><ul><li>Dry mouth </li></ul></ul><ul><ul><li>Fit (1:1,000 or lower) </li></ul></ul>
    55. 55. Cautions for Bupropion <ul><li>Contraindicated in patients with current or past epilepsy </li></ul><ul><li>Contraindicated in patients with a history of anorexia nervosa and bulimia, severe hepatic necrosis, or bipolar disorder </li></ul><ul><li>Caution in patients with conditions predisposing to a low threshold for seizure: </li></ul><ul><li>history of head trauma </li></ul><ul><li>alcohol misuse </li></ul><ul><li>on hypoglycaemic agents or insulin </li></ul><ul><li>drugs that lower the seizure threshold (for example, theophylline, antipsychotics, antidepressants, and systemic corticosteroids). </li></ul>
    56. 56. Summary <ul><li>Most smokers want to stop smoking but need help to do so </li></ul><ul><li>All health professionals should ask and advise about smoking </li></ul><ul><li>Using nicotine replacement therapy or bupropion doubles the chances of a successful quit attempt </li></ul>
    57. 57. Assessment Questions <ul><li>Questions have four stems each of which may be true or false, apart from Question 4 where only one stem is correct </li></ul><ul><li>Answers can be found in the speakers notes accompanying each question </li></ul>
    58. 58. Question 1 – Health effects <ul><li>Non smokers live on average 8 years longer than smokers </li></ul><ul><li>COPD is the commonest cause of death from smoking </li></ul><ul><li>1,000 UK hospital admissions per month are due to smoking related problems </li></ul><ul><li>Smokers stay longer in hospitals than non-smokers </li></ul>
    59. 59. Question 2 - Addiction <ul><li>Most smokers find it easy to stop smoking if they are motivated </li></ul><ul><li>Nicotine can be as addictive as heroin or cocaine </li></ul><ul><li>Nicotine is the main substance in cigarettes that causes harm </li></ul><ul><li>Withdrawal from nicotine peaks at 3 – 5 days after quitting but can last for many weeks </li></ul>
    60. 60. Question 3 – Cessation strategies <ul><li>Half of smokers would like to stop smoking </li></ul><ul><li>Willpower alone is the most effective way to stop smoking </li></ul><ul><li>Around a quarter of those smokers trying to quit do so because of advice from a health professional </li></ul><ul><li>Switching to roll-ups is less harmful than smoking cigarettes </li></ul>
    61. 61. Question 4 – The 5 A’s <ul><li>What are the 5 A’s of smoking cessation ? Only one answer is correct! </li></ul><ul><li>Ask, accept, assess, alter, arrange </li></ul><ul><li>Ask, advise, assess, assist, arrange </li></ul><ul><li>Ask, accept, advise, assess, assist </li></ul><ul><li>Ask, advise, alter, assist, advance </li></ul>
    62. 62. Question 5 - Quitting <ul><li>Cutting down can be useful before quitting </li></ul><ul><li>Because smoking relieves stress, smokers are less stressed than non-smokers </li></ul><ul><li>Using nicotine replacement therapy doubles your chances of quitting successfully </li></ul><ul><li>Using nicotine replacement or bupropion reduces the amount of weight gain when quitting </li></ul>
    63. 63. Question 6 - Attitudes <ul><li>Most smokers smoke out of choice </li></ul><ul><li>Smokers have less willpower than non-smokers </li></ul><ul><li>People who smoke are not eligible for certain treatments from the NHS </li></ul><ul><li>Most smokers will not be able to give up successfully without support </li></ul>
    64. 64. Question 7 – Nicotine Replacement <ul><li>Nicotine replacement therapy doubles the chance of quitting smoking successfully </li></ul><ul><li>Nicotine patches are more effective than gum or lozenges </li></ul><ul><li>Nicotine patches are expensive </li></ul><ul><li>The nicotine nasal spray is the fastest acting nicotine replacement and is good for people who are heavily addicted to nicotine </li></ul>
    65. 65. Question 8 – Bupropion <ul><li>Bupropion is generally safe if used correctly </li></ul><ul><li>Bupropion is more effective than nicotine replacement therapy </li></ul><ul><li>Bupropion should not be used in smokers with COPD </li></ul><ul><li>Bupropion can be used with nicotine replacement therapy under supervision </li></ul>