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Helping smokers who lose the will to quit find it again

Charles Broomhead
MB ChB MRCGP DA DRCOG
GP and GP Trainer
Sutton Coldfield
Honorary Clinical Lecturer
Birmingham Medical School

One of the new strengths of primary care is the way that different disciplines are learning to work together. Nowhere is this better demonstrated than in clinics that have been set up to implement the demands of National Service Frameworks (NSFs). In these, and other settings such as hypertension and asthma clinics, the practice nurse plays a vital role in raising and dealing with the subject of smoking cessation. In reality, nurses may be better trained and informed than the GPs with whom they work and are key workers in this area.
Cigarette smoking is the number one avoidable cause of illness in Britain today, with one in every two lifelong smokers eventually dying as a result of a disease related to their addiction.(1) What this actually means is that 120,000 people in the UK will die every year from a smoking-related disease. This is may be a difficult figure to grasp, and the scale of the problem can be better appreciated once you work out that this represents more than 13 deaths every hour of the day and night, every day of the year.(2) This awful statistic is repeated year after year.
Recent figures show that 29% of men and 28% of women in the UK smoke.(3) A survey commissioned by SCAPE (Smoking Cessation Action in Primary Care) in 2001 showed that 64% of smokers who were questioned wanted to quit. Smokers aged between 25 and 44 years were most likely to want to stop, but even in those aged 65 years or more, 39% wanted to overcome their addiction.(4)
Those of us who work within the NHS are getting better at helping people to stop smoking. Department of Health figures show that 64,000 smokers claim they quit between April 2000 and March 2001 with the assistance of national smoking cessation services.(5)
There can be no doubt that primary care remains the most important initial source of advice for all smokers. This is true not just for those who currently want to quit, but also for those smokers whose medical problems make it essential that they do so. 
A number of important principles apply in relation to any attempt to stop smoking. These include the evaluation of an individual's motivation to stop and the provision of health education information. There should be an assessment and provision of what appears to be the most appropriate methods of support, and, perhaps most importantly, there should be a common approach to the problem by all members of the healthcare team. 
It is certainly true that the more resources that we use to help patients to stop smoking, the greater their chance of success. Studies where medication has been added to other protocols for smoking cessation have generally doubled the chance of success. The patient who is treated in a dedicated smoking cessation clinic with several hours of counselling, and who is supported with quitting aids such as nicotine replacement therapy (NRT) or bupropion (Zyban), will perhaps have a 25% chance of still being an ex-smoker at the end of the year. 
However, we must not forget the major role that can be played by brief advice given by a nurse or GP in a surgery or clinic. Typically this approach has a success rate of about 8%. At first sight this may appear to be much less successful, but it is not an insignificant outcome. Because of the enormous number of patients that we see, this
methodology arguably represents the most efficient way of achieving a nonsmoking society. It has been calculated that if every GP advised an extra 50% more smokers to quit this would result in an additional 75,000 ex-smokers per year in England alone.(6)
At the start of the New Year many of us make well- intentioned resolutions. Unfortunately, less than 30% of these will be successful, but year after year we make the same efforts to improve our lives. One of the most common of these resolutions is to stop smoking. At the beginning of this year it was estimated that more than three million smokers in the UK tried to stop smoking, while a further four million thought about doing so. Stopping smoking is not an easy thing to do; indeed some would argue that it is the most difficult behavioural change that a smoker will ever make. Research in America has shown that the average smoker makes a resolution to stop three years in a row and makes a total of five attempts to quit before succeeding. 
There are many ways in which the chances of becoming a successful ex-smoker can be improved. Perhaps the chief of these is to put some planning and thought into the problem and not simply to decide to give up just before midnight on New Year's Eve! Nevertheless, however well they have prepared themselves and their families, many people will have abandoned their attempt to stop after just a few days or weeks. Some will feel that they have failed and simply forget about the problem until next year, but with encouragement others may still be helped.
There are a number of important things that can be done to help these patients. First, of course, they must be identified, and unfortunately there is no simple way of doing this except by asking them whether or not they smoke. Once found, the sense of failure that many of them will be experiencing should not be reinforced by ill-considered words or implied criticism. Rather, the situation can be used as an opportunity to explain the addictive nature of nicotine and as a platform from which to launch a further, hopefully more successful, attempt. 
There is in fact a good argument for using every opportunity to ask patients whether or not they smoke. We know that many smokers try to conceal their addiction. In a survey conducted by BMRB at the end of 2001, 24% of those smokers who were interviewed admitted that they hid their smoking from someone such as their parents, grandparents, children, other relatives or their doctor.(7) They did this despite admitting that they knew that keeping their secret made them feel guilty or foolish. Once more there appears to be no simple way of identifying these people. The survey showed that men and women were equally likely to be "secret smokers", but the tendency was much more common in the younger age groups.
Lapsed quitters may be too "ashamed" of their perceived failure to ask for further help, and a prompt from a health professional may give them a longed for opportunity to discuss their problem once more. 
An argument used by some doctors for not discussing smoking with their patients is their lack of consultation time.(4) This is undoubtedly true, and although tools such as the SCAPE algorithm (Figure 1), or the "four As" approach,(8) allow a more efficient use of surgery time, there are reasons why nurses may be more successful at helping lapsed smokers to readdress their problem.

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It is often said that patients will confide things to a nurse that they feel inappropriate or unable to discuss with a doctor. They may believe that the doctor's time is too short or too precious, their problem too trivial, or they may just be too intimidated by the doctor to broach the subject. Certainly nurses are generally permitted appointments of appropriate length, and this helps to address at least one of these issues.
In talking to the individual patient it is important to dispel the idea of failure. A better approach is to acknowledge that previous attempts have not been successful and then to explore with that patient the reasons for their lack of success. It is worthwhile spending time explaining that although the benefits to be gained from not smoking are
greatest for younger smokers, it is almost never too late to stop, and that further attempts are sensible. 
Some of the most important health gains that may be useful when talking to smokers about stopping smoking, include:

  • After about 10 years the overall mortality risk falls to that of someone who has never smoked.
  • After 3 years the rate of decline in lung function is similar to that of someone who has never smoked.
  • The risk of lung cancer is reduced by between one-third and a half after 10 years.
  • The risk of coronary heart disease falls by a half after only one year and continues to fall for 10 years, by which time it is similar to that of someone who has never smoked.(9-11)

While it is important for all smokers to quit, it is particularly important for those with a smoking-related disease to do so. For example, smoking cessation has been shown to have the greatest effect in reducing risk in patients with established cardiovascular disease. Very few of us would argue against using a statin to reduce cholesterol levels in those patients who have angina or a history of myocardial infarction. 
However, even using expensive models of smoking cessation, getting these same patients to quit actually represents a much more cost-effective way of saving lives.(12,13) It has been estimated that secondary events can be reduced by up to 50% in those patients who give up smoking, a factor that is recognised in the NSF for Coronary Heart Disease.(14) 
Failed quitters should be encouraged to try again within a few months. Delaying these attempts until motivation has redeveloped is important in order to maximise their chances of success(15) and to avoid a predictable cycle of quit attempt and recurrent failure. It is essential to examine the reasons why a previous attempt to quit has failed. Once these are recognised they can be explored and addressed, and perhaps an alternative or additional form of support provided. No Smoking Day, which is generally held on the second Wednesday in March, may provide a focus and represent an appropriate opportunity for "New Year failures" to try again.

References

  1. Action on Smoking and Health. Smoking statistics: illness and death. ASH fact sheet No 2. London: ASH; 2001.
  2. Secretary of State for Health and Secretaries of State for Scotland, Wales and Northern Ireland. Smoking kills: a White Paper on tobacco. London: HMSO; 1998.
  3. Office of National Statistics; 1997.
  4. Taylor Nelson Sofres. Attitudes to nicotine addiction. London: Taylor Nelson Sofres; June 2001.
  5. News in Brief. Health Serv J 2001;13 December:6.
  6. Tobacco Advisory Group. Nicotine addiction in Britain. London: Royal College of Physicians; 2000.
  7. BMRB. Secret smoker. London: BMRB; December 2001.
  8. Raw M, McNeill A, West R. Smoking cessation guidelines for health professionals. Thorax 1998;53(Suppl 5, Pt1): S1-19.
  9. US Department of Health and Human Services. The health benefits of smoking cessation: a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion and Health Promotion, Office for Smoking and Health; 1990.
  10. American Thoracic Society. Cigarette smoking and health. Am J Respir Crit Care Med 1996;153:861-5.
  11. Rosenberg L, Palmer JR, Shapiro S. Decline in the risk of myocardial infarction among women who stop smoking. N Engl J Med 1990;322:214-7.
  12. Briggs AH, Gray AM. Handling uncertainty when performing economic evaluation of healthcare interventions. Health Technol Assess 1999;3:1-134.
  13. Pharaoh PD, Hollingworth W. Cost effectiveness of lowering cholesterol concentration with statins in patients with and without pre-existing coronary heart disease: life table method applied to health authority population. BMJ 1996;312:1443-8.
  14. Department of Health. National service framework for coronary heart disease. London: Department of Health; March 2000.
  15. Jackson G, Bobak A, Chorlton I, et al. Smoking cessation: a consensus statement with special reference to primary care. Int J Clin Pract 2001;55:385-92.

Resources
Ash (Action on Smoking and Health)
W:www.ash.org.uk
Department of Health
W:www.doh.gov.uk
Healthnet
W:www.healthnet.org.uk
NHS Smoking Helpline
T:0800 169 0 169
W:www.giving upsmoking.co.uk
NHS Pregnancy Smoking HelplineT:0800 169 9 169
Office of the Surgeon General
W:www.surgeongeneral.gov/tobacco
Quit
T:0800 1 697080
W:www.quit.org.uk
Stop Smoking Secrets
W:www.stop-smoking-secrets.com
Tobacco Campaign Helpline Service
T:0800 002200
Tobacco Information and Prevention Source (TIPS)
Centers for Disease Control and Prevention
W:www.cdc.gov/tobacco