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Helping your patients to quit smoking

Jennifer Percival
RGN RGM HVCert FETC HEdCert Counselling Diploma
Manager
RCN Tobacco Education Project

Half of all regular smokers will die prematurely, so helping people to stop smoking saves lives.(1) Smoking, however, is a chronic relapsing condition, and only 2-3% of smokers manage to stop without help. Many nurses become disillusioned when they see their patients relapse, especially if they have little knowledge of the nature of addiction and unrealistic expectations of the quitter. A nurse's support in conjunction with the use of nicotine replacement therapy (NRT) or bupropion (Zyban; GlaxoSmithKline) is effective. A brief intervention in primary care has been shown to give a 5% success rate. This is approximately doubled if the smoker uses a pharmacotherapy product to help them overcome the withdrawal symptoms they experience when they stop smoking.(2) On a population basis this would result in a huge number of lives saved.
 
National guidelines for brief interventions
Evidence-based recommendations have been drawn up that describe the essential features of a brief intervention. As part of their routine clinical practice, nurses should ask about their patients' smoking status and update their clinical records. All patients should be advised to stop, have their motivation assessed, be offered appropriate assistance, follow-up if possible, with referral to a specialist cessation service arranged if needed. Nurses should strongly recommend the use of NRT or bupropion if clinically appropriate and provide accurate information and advice on both.

The five "A"s

Ask
All patients should have their smoking or other ­tobacco use established and updated at every visit. Records should describe patients as a smoker, ­
non-smoker or recent ex-smoker, and should note any ­interest they may have in stopping.
 
Advise
All smokers should be advised of the value of stopping and the health risks of continuing. The advice should be given in a clear, appropriate and ­personalised form.

Assess
Current motivation to stop can be assessed using open-ended questions, such as: "Have you ever considered stopping?" or "Are you interested in stopping now?"

Assist
Assist smokers as they plan their quit attempt. If the smoker would like to stop, cover the following key points in 5-10 minutes:

  • Review past experience: what helped, what hindered?
  • Plan ahead: identify likely problem areas; make plans to overcome them.
  • Tell family and friends and enlist their support.
  • Set a date to stop; advise them to stop completely on that day.
  • Plan what they are going to do about alcohol, social occasions and so on.
  • Encourage the use of NRT or bupropion as a ­cessation aid and give accurate information and advice.

Arrange follow-up
Arrange a follow-up visit and further visits after that if possible. Most smokers make several attempts to stop before finally succeeding (the average is around five to six attempts). Relapse is a normal part of this process. If a smoker has made repeated attempts to stop and failed, and/or experienced severe withdrawal ­symptoms, and/or requested more intensive help, consider referral to a specialist cessation service.

Discussing smoking opportunistically
When applying these guidelines nurses find many smokers overestimate the benefits and underplay the risks of their smoking. Trying to persuade smokers to stop can evoke a verbal tennis match. A non-directive approach is more effective. The role of the nurse is to help the smoker reassess the consequences of continuing and the benefits of stopping. Nurses can facilitate this by asking: "How do you feel about being a ­smoker?" or "Have you made any changes to your smoking recently?" Follow-up with: "Have you had any concerns about your smoking?" "What do you plan to do about it?"
If they have ever stopped, ask for more details on how they got back into it again. Congratulate them on the attempt and see how they feel about making a future attempt.
If it is evident that the smoker has no current intention of stopping, summarise the discussion with information on their attitude to the benefits of continuing alongside their health risk. Inform them that you are open to future ­discussions and can provide help to stop.
If the patient is already motivated to change keep the discussion to a similar format. Rather than provide advice, help them talk through their reasons for wanting to stop, any concerns they may have and their coping strategies, ­including the use of pharmacotherapy products.
 
Developing communication skills
Helping people to stop smoking is always worthwhile as it saves lives. Appropriate training has been shown to help nurses increase the level of support they can provide. Check with your local health promotion service or ­smoking services coordinator for details of their ­communication skills courses.

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References

  1. Department of Health. Smoking kills. A white paper on tobacco presented to Parliament by the Secretary of State for Health. London: HMSO; 1998.
  2. West R, McNeill A, Raw M. Smoking ­cessation guidelines for health professionals: an update. Thorax 2000;55:987-99.

Resources
NHS "Don't give up giving up"
W:www.givingupsmoking.co.uk

Smoking Cessation Advice in a Nutshell
Available from GASP
T:0117 9425185

Further reading
RCN. Clearing the air - a nurse's guide to smoking and tobacco control. London: RCN Publications; 2001.

STOP! A guide to smoking cessation in primary care.
Stop! Ltd; 2001. Costs £7.99 plus p+p
T:01227 779229