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Discussing smoking saves lives!

Jennifer Percival
RGN RM RHV
RCN Tobacco Education Project Manager
E:jennifer.percival@usa.net

The answer is "Yes" because smoking causes one in five deaths and remains the single greatest cause of preventable illness and premature death in the UK. Every smoker has a one in two chance of being killed by their smoking,(1) and smokers are more likely to develop coronary heart disease, lung cancer, chronic bronchitis or emphysema than nonsmokers.
When you take into account the fact that smokers cost the NHS up to 40% more than nonsmokers, the case for primary care intervention is made.(2)

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Government action
Many legislative changes have taken place over the last six years. The government has introduced a comprehensive ban on tobacco advertising, put larger warnings on tobacco products and made nicotine replacement therapy (NRT) products available on NHS prescription. A mass media antismoking campaign drives smokers to the NHS Smoking Helpline (0800 169 0 169) and to the now established NHS Stop Smoking Services. As a result of all this activity we have seen a decline in adult smoking from 28% in 1998 to 25% in 2004.(3)
New government targets are focusing on disadvantaged groups. The Public Service Agreement (PSA) includes the target "to reduce adult smoking rates to 21% or less by 2010, with a reduction in prevalence among routine and manual groups to 26% or less".(4)
 
How you can help smokers to quit
Although 70% of smokers surveyed say they would like to stop, due to the highly addictive nature of nicotine the unaided success rate is 1-2%.(5)
A primary care professional's intervention and encouragement to quit smoking may be the most important influence on their patients' health. Clinical guidelines confirm that a combination of nicotine replacement therapy and support works best - even highly addicted smokers have been shown to achieve success.(6)
The clinical guidelines recommend using the "4 As" approach:

  • Ask - all patients should have their smoking status checked regularly.
  • Advise - give all smokers personalised advice on the benefits of quitting.
  • Arrange - motivated quitters should be referred to a cessation service.
  • Assist - give assistance to smokers unwilling to be referred to a specialist.

Ask
All patients should have their smoking status established and checked at regular intervals. A simple and quick system should be devised to enable smoking details to be recorded in the patient's clinical notes (GP computer systems such as EMIS enable recording of smoking status). The following questions can help you determine a patient's motivation to stop smoking.

  • Do you want to stop smoking for good?
  • Are you interested in making a serious attempt to stop in the near future?
  • Are you interested in receiving help with your quit attempt?

A positive response to these questions provides a basis for offering assistance.

Advise
All smokers should be advised of the value of stopping and the risks to their health of continuing. Smokers know that smoking is dangerous, but few realise the full extent of the risks. Hearing this message from their GP or primary care nurse can motivate them to consider stopping. The advice should be clear, firm and personalised.

Arrange
If your practice does not offer a specialist smoking cessation service, refer the smoker to your local NHS Stop Smoking Service.

Assist
These are the key points to cover when a patient wishes to stop smoking:

  • Help them decide a date to stop.
  • Prescribe a suitable pharmacotherapy product. NRT or bupropion (Zyban; Glaxo Wellcome) are endorsed by NICE guidelines.
  • Review past experience: what helped and what hindered them?
  • Ask them to identify future problems and make a plan to deal with them.
  • Encourage them to get support from family and friends.
  • Give them the NHS self-help book, Giving up for Life.

Follow-up
Monitoring a smoker's progress during a quit attempt is essential. A follow-up appointment one or two weeks after the quit date allows you to check on their progress and offer a further prescription of their treatment product. Praise and encouragement will help motivate and maintain a patient's determination to succeed.
 
Withdrawal symptoms
Although the majority of smokers want to stop, only a small number are likely to succeed on any given attempt. This is due to their addiction to nicotine and the withdrawal symptoms they experience when they stop smoking. Reassure smokers that these symptoms are a normal sign of recovery and encourage them to use the full course of their treatment product. Carbon monoxide monitoring is a useful tool to establish pre- and postcessation levels and to validate the patient's nonsmoking status.

NICE recommendations
In 2002, the National Institute for Clinical Excellence (NICE) produced guidance on NRT and bupropion after evaluating their clinical effectiveness.(7) NICE recommended that both products were effective for treating addiction to tobacco and should be offered to smokers who expressed a desire to quit smoking. NICE highlighted that providing quitters with advice and support was of major importance. They suggested that the initial NRT prescription should be sufficient to last two weeks from the quit date, with further prescriptions given as the quit attempt continues successfully. NICE concluded that there was insufficient evidence to assess whether one form of NRT is more effective than another. NICE stated that prescribing NRT or bupropion was among the most cost-effective of all healthcare interventions.

NHS Stop Smoking Services
A comprehensive network of free NHS Stop Smoking Services has been set up across England to provide counselling and support to smokers. Smokers can self-refer to these clinics. Stop-smoking advisers meet smokers individually or as part of a group for up to an hour a week for six or seven weeks. The first two sessions are usually spent planning and preparing to give up, and then quitting takes place in the third week. Appointments are then set for the following four weeks to support the smoker through the first month of quitting.
Each PCT has a target to meet, and in some areas a separate payment is made to practices for undertaking this work. Many practices work with their local service providers and fill in the Department of Health's monitoring forms collecting data on the four-week results.
A quit attempt with support through local services has been shown to increase a smoker's chances of quitting by up to four times. Between April 2004 and March 2005, nearly 529,520 smokers set a quit date with the NHS Stop Smoking Services. Around 297,828 said they had successfully quit when followed up four weeks later (based on self-report), 56% of those setting a quit date.(8)
 
The "Don't Give Up Giving Up" campaign
A government-funded mass media publicity campaign is being run that provides information and encouragement to smokers and resources for healthcare professionals. A wide variety of free resources for use in the surgery are available from the NHS Smokers Helpline — 0800 169 0 169 — or via the NHS websitewww.givingupsmoking.co.uk

Conclusion
Stopping smoking prolongs life regardless of the age at which a person quits. Brief interventions by GPs and primary care nurses have a positive impact and are well worth the time invested.

References

  1. Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years' observations on male British doctors. BMJ 1994;309:901-11.
  2. Buck D, Godfrey C. Helping smokers give up: guidance for purchasers on cost-effectiveness. London: HEA; 1994
  3. Office for National Statistics. Omnibus surveys in Oct and Nov 2003: smoking-related behaviour and attitudes. Available from URL:http://www.statistics.gov.uk
  4. Her Majesty's Treasury. 2004 Spending Review: Public Service Agreements 2005-2008. London: HM Treasury; 2004
  5. Royal College of Physicians Nicotine addiction in Britain - a report of the Tobacco Advisory Group of the Royal College of Physicians. London: RCP;2000.
  6. West R, McNeil A, Raw M. Smoking cessation guidelines for health professionals: an update Thorax 2000;55:987-99.
  7. NICE Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation. Guidance no 38. London:NICE;2002.
  8. Statistics on NHS Stop Smoking Services in England, April 2004-march 2005. Available from URL:http://www.dh.gov.uk/PublicationsAndStatistics/Publications/Publications...

Resources
NHS Giving Up Smoking website W:www.givingupsmoking.co.uk

ASH - Action on Smoking and Health
W:www.ash.org.uk

Quit
W:www.quit.org.uk

British Heart Foundation
W:www.bhf.org.uk/smoking

Cancer Research
W:www.cancer
researchuk.org/aboutcancer/reducingyourrisk/smoking

No Smoking Day
W:www.nosmokingday.org.uk