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Health inequalities and smoking cessation

With the focus turning to health inequalities there's never been a more important time to help people stop smoking. Jennifer Percival reviews the impact of smoking on health inequalities and outlines a range of strategies that will support your patients to give up cigarettes

Jennifer Percival
RN RM RHV FETC
Diploma in Counselling
Royal College of Nursing Tobacco Policy Advisor

Fact: smoking kills approximately half of all regular smokers. Fact: smoking is the single biggest cause of health inequalities in the UK. Fact: on average, those killed by smoking have lost 10-15 years of life.
The latest government figures from the Information Centre, show a big increase in quitters following the smoke-free legislation in England, which came into force on 1 July 2007. There has also been an unprecedented demand for stop smoking services from the public.(1)
Unfortunately, when it comes to smoking there is a pronounced class divide as 34% of men and 30% of women in routine and manual groups smoke, compared with 20% of men and 17% of women in the professional and managerial groups.(2) Smoking accounts for half the difference in life expectancy between social class 1 and 5.(3)
To tackle this the Department of Health has set a public service agreement (PSA) target to reduce smoking rates to 21% or less by 2010, with a reduction in prevalence among routine and manual groups to 26% or less.(4) Achieving this target would greatly reduce health inequalities.
Evidence shows that routine and manual workers are no less likely to want to quit smoking than anyone else, but they are less likely to succeed. People from socially disadvantaged groups are more likely to have been exposed to tobacco smoke as they grew up, be more likely to start smoking from a very young age, smoke more cigarettes per day and take more nicotine and tar from each cigarette than less disadvantaged smokers.(5) It's the combination of these factors that makes it harder to stop smoking.
Staff working in primary care need to be advising all smokers to quit and offering structured support; or referring them to the NHS Stop Smoking Services. Unfortunately this is only happening in a minority of cases.(6) This needs to change because over 80% of the population visit GPs at least once a year, with the figure even higher for smokers. Primary care teams need to check their systems to ensure every smoker is identified and advised to quit, unless there are exceptional circumstances.
A tool to identify the smoking rates and deprivation in every ward in England has been published online by Action on Smoking and Health.(7) Use this to establish the actual prevalence within your practice population. Present the figures at a team meeting and discuss ideas on how you could make your current services more attractive to disadvantaged smokers. Ideas can range from putting up an interactive display around "no-smoking days" with free balloons for children, to adapting the times you open, or running a coffee morning with a crèche facility during a baby clinic. Routine carbon monoxide monitoring can also be offered to everyone in the waiting areas. Make it fun, the idea is to get people chatting generally about smoking to reduce their fear of a one-to-one session.

Personalise the benefits of stopping smoking
Whatever a person's background or smoking history it is never too late for them to benefit from stopping. Giving up smoking is particularly important for those patients who already have high blood pressure, raised blood cholesterol levels, are overweight or suffer from diabetes. Unfortunately, its not unusual for the committed long-term smoker to believe any "damage" caused by their habit has already been done. It can be very frustrating when you explain the immediate benefits of quitting and are met with resistance and a complete lack of motivation.
Ask "What damage do you think has been done?". It helps to listen and clarify the situation by listing their risk factors. This opens the door for you to be able to explain the other immediate benefits of giving up smoking. Encourage them to believe its possible to stop. Ask "Do you know anyone who has become ill from smoking?", or "How would it affect your life if something happened to you?".
Stopping smoking may be the one thing they can change that will reduce their immediate risk of long-term illness (see Table 1).

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What works best?
The answer is a combination of advice, motivational support and appropriate treatment. Brief advice is effective in reducing patients' smoking and NICE guidance was issued on this topic last year.(9) There is no quick fix to ending addiction to nicotine and socially deprived smokers relapse several times before they finally succeed.
Ask "What would have to change for you to be able to go without smoking?". If they are having "just one or two cigarettes" ask "How are you managing to stay at such a low level?". Be patient and don't apply pressure if the progress is slower than you hoped. Support all efforts and changes.

Treatment for nicotine addiction
Many smokers experience problems when trying to quit. One of the main reasons stopping smoking is difficult is because the body craves the nicotine it used to get from cigarettes. These strong feelings make people feel irritable and anxious and they can fall into the trap of thinking returning to smoking is the only way to "fix" the problem. Encourage all potential quitters to use nicotine replacement therapy, Zyban [GlaxoSmithKline] or Champix [Pfizer], as these will double their chances of success.

Nicotine replacement therapy (NRT)
NRT is an effective treatment for tobacco dependence, which has been shown to significantly increase a smoker's chances of stopping. NRT is a safe and effective treatment for tobacco dependence, giving immediate and significant health benefits to the former smoker.(10)
This fact was endorsed in 2005 when the Medicines and Healthcare products Regulatory Agency (MHRA) changed the licensing arrangements for NRT products.(11) Many of the contraindications, warnings and restrictions on NRT use were lifted. All forms of NRT can now be used by patients with heart and circulatory disease, in smoker's aged 12 and upwards and in pregnancy. More than one form can be used together and NRT can be prescribed for up to nine months if there is evidence of a continued need for treatment beyond the 8-12 week treatment period. NRT can also be used while still smoking, to reduce consumption and manage temporary abstinence.

Using combination therapy
Combining two NRT formulations, for example the skin patch with an oral product, can provide additional relief from withdrawal symptoms. Encourage people to recognise early withdrawal symptoms and top up their blood nicotine levels with a second NRT product. This is much better than using a cigarette and achieves the same result.

Cutting down before stopping?
If a smoker asks you about cutting down it is important to explore their thoughts. Ask "Why have you decided to cut down?" Find out what they don't like about smoking and how much they want to change. Complete cessation needs to remain the "gold standard" for all smokers, but many feel unable or unwilling to stop abruptly. Cutting down with therapeutic nicotine will keep their blood nicotine level up making it easier for them to smoke less cigarettes. The NRT inhalator and gum are licensed for use in this way. By reducing a smoker's reliance on tobacco for nicotine intake, some previously sceptical smokers found they could stop smoking completely. A guide to using this approach is on the ASH website.(12)

Oral medications
Bupropion (trade name Zyban), is an atypical antidepressant that was discovered to help smokers quit. The exact way it works for smoking cessation is not known, but it is thought to act via the dopaminergic and noradrenergic pathways that play an important role in nicotine dependence and withdrawal.(13) However, as Zyban is an antidepressant there are a number of contraindications and cautions to be considered before prescribing, which may exclude some people from using this medication. Zyban is taken in tablet form, one tablet for the first few days and then one tablet twice a day for the remainder of the eight-week course. As Zyban takes one to two weeks to become effective, smokers need to set a quit day accordingly.
Varenicline, the latest drug designed to treat nicotine addiction, was launched in December 2006 under the brand name Champix. Varenicline comes in tablet form and partially stimulates the dopamine receptor to cause some dopamine release and therefore reduces the craving and withdrawal symptoms associated with stopping smoking. At the same time, Varenicline blocks nicotine from working at the receptor, so if the smoker lapses and has a cigarette, the pleasure and satisfaction associated with smoking are reduced. 
The treatment course is usually 12 weeks but this can be doubled if necessary. In two clinical trials, 44% quit smoking by the end of 12 weeks, and a year later around one in five still didn't smoke.(14) It can be used by smokers with CHD, but is contraindicated in those under 18 years, pregnant women and in people with epilepsy.

Summary
As a nurse working in primary care you are in an excellent position to help people to stop smoking. There has never been so much support available via the NHS and with the changes in the law making it harder for smokers to light up; many will feel the time has come for them to make the effort to quit. For every two people you help to stop you will have saved one life. Watch out for people who may be making their first ever attempt and those from disadvantaged backgrounds. They are likely to need more time and patience but seeing them succeed the results will be well worth your efforts.

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References

  1. NHS. The Information Centre. Available from: http://www.ic.nhs.uk
  2. Office for National Statistics. General household survey 2003/04. London: ONS; 2004. Available from: http://www.statistics.gov.uk/ghs
  3. Wanless D. Securing good health for the whole population. London: TSO; 2004.
  4. Department of Health. Public service agreement. London: DH; 2004.
  5. Nicotine Addiction in Britain. A report of the tobacco advisory group of the Royal College of Physicians. London: RCP; 2000.
  6. Taylor T, Lader D, Bryant A, Keyse L, McDuff TJ. Smoking-related behaviour and attitudes. London: ONS; 2006.
  7. ASH. Major online mapping project shows "iron chain" between smoking and deprivation. Available from: http://www.newash.org.uk/ash_b5hdcln5.htm
  8. QUIT charity. Available from: http://www.quit.org.uk
  9. NICE. Brief interventions and referral for smoking cessation in primary care and other settings. London: NICE; 2006.
  10. NICE. Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation. Technology Appraisal Guidance 39. London: NICE; 2002.
  11. Committee on Safety of Medicines & Medicines and Healthcare Products Regulatory Agency. Report of the committee on safety of medicines working group on nicotine replacement therapy. London: CSM & MHRA; 2006. Available from: http://www.mhra.gov.uk
  12. ASH. Nicotine-assisted reduction to quit (NARS). Guidance for health professional on this new indication. 2005. Available from: http://newash.org.uk/files/documents/ASH_452.pdf
  13. Roddy E. Bupropion and other non-nicotine pharmacotherapies. BMJ 2004;328:509-11.
  14. Tonstad S, Tonnesen P, Hajek P, Williams KE, Billing CB, Reeves KR. Varenicline Phase 3 Study Group. Effect of maintenance therapy with varenicline on smoking cessation: a randomized controlled trial. JAMA 2006;296:64-71.

Resources
McEwen A, Hajek P, McRobbie H, West R. Manual of smoking cessation. Oxford: Blackwell; 2006.

Percival J. Clearing the air 2: smoking and tobacco control - an updated guide for nurses. London: RCN; 2005. Copies available from RCN Direct 0845 772 6100.

Percival J. You can stop smoking - your personalised plan to give up for good. London: Virgin; 2007.

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

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

Cancer Research 
W: www.cancerresearchuk.org

Click2Quit 
W: www.click2quit.com

Department of Health
W: www.gosmokefree.co.uk

For more information on the legislation visit
www.smokefreeengland.co.uk