Key learning points:
- Smoking kills half of long-term users
- Exposure to second-hand smoke is a health hazard
- Make every contact count as research shows that the more help smokers get the better their chances of stopping
Smoking kills half of all long-term tobacco users so it’s not surprising that around 70% of smokers want to quit the habit (1). Research shows that the more help smokers get the better their chances of stopping (2) so primary care nurses have the opportunity to offer supportive guidance to smokers who want to quit, either in the clinical setting or while on home visits.
All health and health-related staff can and should raise the issue of stopping smoking in their day-to-day work with patients and clients and, where appropriate, refer them on to local services to help them stop (3).
Tobacco users may be aware of some of the health problems they could suffer due to smoking, such as cancer (4). Tobacco is also a risk factor in other conditions primary care staff encounter, such as cardiovascular disease, chronic obstructive pulmonary disease6 and even dementia (5).
Health visitors, for example, can advise smokers of the dangers of second-hand tobacco smoke.
Primary care staff who perform minor surgeries or are nurse practitioners should note smoking impedes recovery from surgery, is associated with post-operative complications, impaired wound healing and admission to intensive care units (6).
Nurses can play a key role in helping smokers who are ready to quit by making themselves aware of the types of cessation aids available and by signposting people to support from a range of services. These include GPs, pharmacists and NHS national freephone services.
Using willpower alone to give up may not work for some, so it’s important smokers are made aware that there is a greater chance of success when the support of NHS cessation services is combined with stop-smoking medication such as nicotine replacement therapy (NRT), varenicline (Champix) or bupropion (Zyban). All three are more effective backed by expert advice (4).
NICOTINE REPLACEMENT THERAPY (NRT)
NRT gives the body a lower amount of nicotine than a smoker would get from using tobacco, without the exposure to the harmful contents of cigarettes like tar, cyanide and carbon monoxide. Nicotine is highly addictive so replacing some of the nicotine from tobacco eases unpleasant withdrawal symptoms while people get used to becoming a non-smoker. A full course of treatment usually lasts for eight to 12 weeks.
NRT is available over the counter or on prescription from a GP or stop-smoking service. It’s licensed for use by pregnant or breastfeeding women, young people over 12, and those with underlying conditions such as cardiovascular disease.
Nicotine patches are the most popular form of NRT. They can be worn round the clock – helpful for people who have strong cravings in the early morning – or only during the time they are awake (16-hour patches). Patches come in different strengths and their use can be gradually reduced over time before stopping completely.
They can be worn discreetly beneath clothing and may suit those who dislike the taste of oral NRT products.
Gum is the second most commonly used type of NRT, available in 2mg or 4mg strengths and various flavours, such as mint and fruit. The nicotine is absorbed through the lining of the mouth. People who smoke 20 or more cigarettes a day should normally start with the stronger gum.
When smokers first quit they may find chewing about one piece of gum every hour helpful, chewing until the taste becomes strong or hot and then holding the gum inside their cheek to help nicotine absorption.
Gradually they can begin to cut down on the amount of gum – chewing for shorter periods, using smaller pieces, using the lower-dose gum or alternating with a non-nicotine gum.
Gum can be helpful because it provides short bursts of nicotine. The taste may be unpleasant at first but most people get used to it in a week or so.
This product delivers a swift dose of nicotine through the lining of the nose. It’s the fastest way that nicotine can enter the bloodstream, reaching the brain within 10 minutes, with each dose giving an amount of nicotine equivalent to one cigarette.
It should be used no more than five times an hour and no more than 40 doses a day, for a total of 12 weeks. Patients use between one and two sprays an hour for the first eight weeks depending on how heavy a smoker they are, before reducing and stopping.
They can be used directly to counter cravings for a cigarette – and mimic the “rush” from smoking more closely than any of the other forms of NRT. However, the spray may cause nose and throat irritation, coughing and watering eyes.
An inhalator is sucked on and releases nicotine vapour, which gets absorbed through the mouth and throat. It’s good for people who miss the “hand to mouth” ritual of smoking.
Inhalators work swiftly so patients are advised to use them when they feel strong cravings for a cigarette. Each inhalator contains a disposable cartridge which has enough nicotine for three to four 20-minute puffing sessions – around 400 puffs.
People should aim to use the inhalator for a total of 12 weeks, reducing as they go and finally stopping completely.
Lozenges are put in the mouth and dissolve in 20-30 minutes to release nicotine. Users suck the lozenge until the taste becomes strong or hot. After this they rest the lozenge inside their cheek.
They are used for about 12 weeks – one lozenge every one to two hours over the first six weeks, followed by a steady reduction. Lozenges are helpful because they provide short bursts of nicotine. They should not be used by people with mouth ulcers.
These are small tablets containing nicotine that dissolve quickly under the tongue. People should use one or two tablets every hour for up to three months after quitting, before cutting back and stopping them.
Some people find microtabs are more discreet than other oral products, as there is no chewing or sucking. They can be used by smokers who are trying to cut down the number of cigarettes they smoke, as well as those who have quit completely. Patients should stop smoking within six months of starting on microtabs.
Champix is a tablet that has been specifically developed to help people quit smoking. It works by reducing cravings and withdrawal symptoms, and also lessens the effects people feel if they do have a cigarette.
It is started one to two weeks before a smoker’s quit date and is only available on prescription and to people over 18.
GPs can prescribe the medication and advise on its use – it is not available to pregnant women or to those with some pre-existing conditions.
Zyban does not contain nicotine and its action is not fully understood. Smokers start taking Zyban one to two weeks before they quit and treatment usually lasts for a couple of months to help them through the withdrawal cravings. It's only available on prescription and to people over 18 and is not available to pregnant women or to those with some pre-existing conditions.
Both drugs have contraindications and patients may have specific concerns raised by media reports, which is why a doctor’s assessment and guidance is needed.
These increasingly popular battery-powered devices deliver a hit of nicotine or flavoured vapour to the user. They are not licensed for medicinal use, but some stop-smoking services offer advice on them.
Although e-cigarettes are regarded as much safer than cigarettes, currently most services advise people to use licensed products as a first line of treatment.
Public Health England advises stop-smoking services can provide behavioural support to people using electronic cigarettes and can start a course of NRT in conjunction with using these devices (7).
Latest guidance in Scotland makes it clear that the priority should be to prevent ex-smokers relapsing to tobacco, and users of e-cigarettes who are not prepared to switch to licensed NRT should not be advised to stop using e-cigarettes if it is likely to mean they would start smoking again (8).
Primary care nurses have the opportunity to identify and record the tobacco use of their patients, remind smokers at every suitable opportunity of the health benefits of stopping and the services and cessation aids available, and the potential to prescribe pharmacotherapies. By taking these opportunities they can save lives.
1. Rutherford L, Hinchliffe S, Sharp C (eds). Scottish Health Survey 2013 – supplementary web tables. Scottish Government; 2014. www.gov.scot/Topics/Statistics/Browse/Health/scottish-health-survey/Publ... (accessed 18 February 2015)
2. West R, Owen L. Estimates of 52-week continuous abstinence rates following selected smoking cessation interventions in England; 2012. www.smokinginengland.info Version 2 (accessed 18 February 2015)
3. NHS Health Scotland, ASH Scotland. A guide to smoking cessation in Scotland 2010; 2010. http://www.healthscotland.com/documents/4661.aspx (accessed 18 February 2015)
4. U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services; 2014.
5. Anstey KJ, von Sanden C, Salim A, O’Kearney R. Smoking as a risk factor for dementia and cognitive decline: a meta-analysis of prospective studies. American Journal of Epidemiology 2007; 166: 367-78. doi: 10.1093/aje/kwm116 (accessed 18 February 2015)
6. Grønkjær M, Eliasen M, Skov-Ettrup LS, Tolstrup JS, Christiansen AH, Mikkelsen SS, Becker U, Flensborg-Madsen T. Preoperative smoking status and postoperative complications: a systematic review and meta-analysis. Annals of Surgery 2014; 259(1): 52-71. doi: 10.1097/SLA.0b013e3182911913 (accessed 18 February 2015
7. McRobbie H. Electronic cigarettes. National Centre for Smoking Cessation and Training; 2014. http://www.ncsct.co.uk/usr/pub/e-cigarette_briefing.pdf (accessed 18 February 2015)
8. NHS Health Scotland, ASH Scotland. A guide to smoking cessation in Scotland 2010: addendum on tobacco harm reduction; 2014. http://www.healthscotland.com/documents/4661.aspx (accessed 18 February 2015)
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