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A new way to help people stop smoking

Jennifer Percival
RN RM RHV FETCDip
Project Manager
RCN Tobacco Education

Even with the availability of effective treatments to aid cessation, reduction in the UK's smoking prevalence has slowed down over the past decade, indicating greater action needs to be taken if we are to meet the government's prevalence target of 21% by 2010.(1) Despite the range of extensive support available in GP surgeries and through local stop-smoking clinics, 26% of the population still smoke. Continued tobacco use remains the greatest cause of premature death in our society, which means that one of the most valuable ways a nurse can spend time is helping people to stop smoking.
Experts have recognised that pioneering solutions are needed to help more smokers give up, and the National Institute for Health and Clinical Excellence (NICE) has recommended that, given the cost-effectiveness of nicotine replacement therapy (NRT), innovative strategies should be pursued.(2) Being able to offer smokers something new is the only way we are going to achieve a greater reduction in prevalence and meet the government's targets. Likewise, by providing more options to suit a broader range of individuals' needs, we can encourage more smokers to stop.
NRT, a proven treatment for tobacco dependence, has been available on prescription since 2001 for smokers who are ready to set a quit date and stop abruptly. In August 2005, two specific formulations of NRT were licensed as part of the "Cut down then stop" programme to allow smokers to use them to cut down their consumption before they stop completely. Smokers who are not ready or willing to stop abruptly can now use these specific types of NRT to relieve cravings while reducing the number of cigarettes they smoke. The aim of the programme is to help the smoker stop completely, in easy manageable stages, across a 6-9-month period.
This new way of using NRT is being introduced to the public in a television advertising campaign. The film shows a man sitting at his desk on a wet and windy day. A colleague asks for a cigarette and enquires if he'll join him. The man replies he's cutting down and puts a piece of NRT gum into his mouth. Outside the other man fruitlessly tries to light up and is eventually blown over by the storm. The slogan says "Cut down with Nicorette then stop". As your clients and patients are likely to see this ad on television, it will be useful to know how to offer support when they ask you about using NRT in this way.

Historical use of nicotine replacement therapy
Research has shown that using NRT during an attempt to stop smoking doubles a smoker's chance of giving up successfully.(3) NRT is available on prescription, as an over-the-counter product in pharmacies and on general sale. NICE recommends that NRT should be prescribed for smokers who have made a commitment to stop smoking by a particular date, and that advice and support should be provided through referral to a stop-smoking service. The combined use of support, advice and NRT further increases the chances of successfully stopping smoking.

How does NRT help people stop smoking?
When deprived of nicotine, a smoker will experience withdrawal symptoms such as depressed mood, irritability, poor concentration, sleep disturbance, hunger and, most importantly, urges or cravings to smoke. Compared with cigarette smoking, NRT provides lower doses of nicotine, which are delivered more slowly and in a controlled way, thereby lessening the severity of the withdrawal symptoms and cravings for cigarettes.
Using NRT allows the smoker to concentrate on breaking the social and psychological habits and also managing the physical cravings. There are several NRT products available, including: chewing gum, skin patches, nasal spray, sublingual microtab, lozenge and inhalator. As yet there is no controlled trial evidence favouring one of these NRT products over another.
NRT can help smokers stop, even if they have tried it before, but it is not a magic cure. It does not provide a complete replacement for cigarettes, nor eradicate the need for willpower, but it will help to reduce withdrawal symptoms such as irritability, depression and craving. All NRT products have similar success rates, so the choice between them is a practical and personal one.
Despite NRT being deemed by NICE as one of the most cost-effective health interventions, uptake and compliance have been poorer than expected as many smokers wrongly think it's nicotine that causes cancer. This is probably due to a general poor comprehension of the fact that it is the myriad of toxins in cigarette smoke and not the nicotine content that is responsible for the majority of the harmful effects of cigarettes.(4)

Which products have been licensed for this technique?
Currently, this new licence is unique to two formulations: Nicorette Gum and Nicorette Inhalator.
Nicorette Gum in 2mg or 4mg doses: A chew-rest-chew technique is recommended as the nicotine should be absorbed by the mucous membrane and not swallowed. This involves chewing the gum slowly until there is a strong nicotine taste. The gum is then "parked" between the cheek and teeth, where the nicotine is absorbed through the cheek lining. The gum should be chewed until the nicotine taste fades. The dosage should be individualised according to the smoker's daily intake of cigarettes and their tobacco dependence.
Nicorette Inhalator: The inhalator addresses the behavioural (hand-to-mouth action) and sensory stimuli ("feel" of smoke at the back of the throat) offered by smoking. It consists of a plastic mouthpiece and nicotine cartridges that fit on the end of it. Smokers draw on it like a cigarette. The nicotine does not reach the lungs, but stops in the mouth, and throat where it is absorbed by the mucous membranes. The inhalator should be used whenever there is the urge to smoke, up to a maximum of 12 cartridges per day.

Measure of success
The clinical trials showed that one in three smokers who successfully cut down their cigarette consumption by 50% with this programme had stopped smoking within one year.(5) Further evidence suggests that a reduction in the number of cigarettes smoked is associated with a greater likelihood of cessation, in smokers not ready to quit but willing to reduce smoking,(6,7) and this increases significantly if reduction is greater than 50%. It's also important not to confuse this new strategy with either harm reduction (reduced cigarette consumption without planned cessation) or merely cutting down without the use of NRT.
More information on the evidence and copies of relevant research can be seen on the ASH website at: www.ash.org.uk/html/cessationdetail.php#reduction

How will this new indication affect nurses?
Most smokers say they'd like to give up one day and have some personal experience of trying. In practice a smoker typically makes five to seven attempts to quit before achieving ultimate success. In some cases, it can be several years after a failed attempt before the smoker will try again.(8,9) Nurses will have heard many patients describe the struggles they have had trying to give up despite a health imperative, as relapse is very common among smokers. Nurses will now be able to describe the cutting down approach to those smokers who want to change their smoking habit but are not able to stop immediately. With no two smokers being alike, it is important for nurses to recognise the unique needs of each person and help them make changes to their smoking habit. Almost all smokers agree they smoke more cigarettes than they like and are able to identify some cigarettes they can do without.

Safety of "Cut down then stop"
It's important to address the concern people may have over the safety of combining NRT with smoking. In theory, the use of NRT while smoking could increase the risk of a nicotine overdose as smokers are getting nicotine from two sources.(10) However, the safety of Nicorette use alongside cigarette smoking was assessed in the "Cut down then stop" clinical trial programme and the results showed that simultaneous use of this NRT and tobacco is well tolerated.(11) The adverse event profile is similar to that seen in abrupt cessation studies. The new product information specifications have removed the contraindications for pregnancy and breastfeeding that have previously applied to other forms of NRT.

Practical implementation
Complete cessation will always remain the "gold standard" for smokers. "Cut down then stop" is an opportunity for nurses to address quitting from a fresh angle. The intention is to increase the number of ex-smokers in the UK. This new indication should not therefore detract from the current smoking cessation programmes. The use of NRT in this way helps the client maintain their desired blood nicotine level without needing to smoke the same number of cigarettes as previously, or to inhale more deeply because they are smoking fewer cigarettes. By using NRT to reduce their consumption, smokers can learn how to deal with cravings and take more control over their smoking habit. As a result they will feel more confident about stopping completely.

Working with the new approach
By asking a series of simple questions, nurses can assess the smoker's current motivation to quit and identify those clients suitable for the new strategy. Applying knowledge of the patient's tobacco use and medical history will help when making the initial intervention.
Each smoker has different reasons for when and why they smoke, so it is necessary to work towards realistic and achievable goals. It is important for smokers to identify for themselves those cigarettes they want to cut out. In practice these will be the more routine ones.
As the goal is to cut out 50% of the current cigarettes being smoked in the first six weeks, it's important to review their progress during this time. Smokers are all different, so they need to decide which cigarettes to cut out first. If after a week no change has been made, ask what has been stopping them. Check whether they have any unexpressed fears about the technique. They may simply need a little more reassurance and affirmation to get started on the programme. Congratulate positive changes and encourage them to continue with the programme. Follow ups over the six-month period can be done face to face or on the telephone. When your patient has stopped smoking completely for four weeks ,they can be counted into the PCT's cessation targets.

Conclusion
The "cut down then stop" approach will enable nurses to engage many more smokers in discussion and offer fresh help to those who previously have not been able to stop smoking abruptly. Successful reduction increases the intention to stop and promotes subsequent quitting, meaning that this new approach is definitely worth trying.

References

  1. Jarvis MJ. Addiction 2003;11:1569-74.
  2. NICE. Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation. Technology Appraisal Guidance No. 38. March 2002.
  3. Silagy C, et al. Nicotine replacement therapy for smoking cessation. In: The Cochrane Library 2001;1.
  4. Efficacy key findings. Available at: http://www.treatobacco.net/safety/show Reference.cfm?kid=1&sid=3 References
  5. Pfizer Consumer Healthcare. Data on file - CDTS 001.
  6. Landfeldt, et al. Smoking reduction with a 4mg nicotine gum - final results from a placebo-controlled trial over 13M. Presented at the 5th European Society for Research on Nicotine and Tobacco meeting, Padua, Italy, Nov 20-22, 2003 (full paper submitted to Clin Pharmacol Therapeutics Q4 2004).
  7. Rennard, et al. Efficacy of nicotine inhaler in smoking reduction. Poster presented at the European Society for Research on Nicotine and Tobacco meeting, Paris, Sept 2001 (full paper submitted to Nicotine and Tobacco Research).
  8. Hughes JR.Tobacco Control 1999;8:323-6.
  9. Ruppert RA. Am J Nurs 1999;99(11):26-32.
  10. Benowitz NL, Zevin S, Jacob P.J Clin Pharmacol Exp Ther 1998;287:958-62.
  11. Bolliger CT, Zellweger J-P, Danielsson T, et al. BMJ 2000;321:329-33. 

Resources
Action on Smoking and Health (ASH)
W:www.ash.org.uk

NHS Smokers Helpline
The patient information and self-help to stop smoking book
Giving up for life is available free by calling this helpline
T:0800 169 0 169