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The Nursing in Practice smoking cessation survey

The Department of Health recognises that primary and community healthcare professionals are in a key position to help patients stop smoking. The latest NiP survey aimed to find out the resources you have access to and how confident you are about giving smoking cessation advice to your patients

Polly Moffat
Editor
Nursing in Practice

Smoking-related illnesses are on the increase and have become a significant drain on NHS resources, with community and primary care professionals dedicating more of their time to
managing and treating conditions caused by smoking.

Every year, around 114,000 smokers in the UK die from smoking-related causes. There are about 9.4m adults who smoke in Great Britain; this is around a sixth of the total UK population.1

In 2006, 68% of smokers who were asked said they wanted to give up, and nine in 10 mentioned at least one health-related reason for doing so.2 For smokers with children in the household, the belief that second-hand smoking could have a damaging effect on children's health was a motivation to stop, given by almost 40% of both men and women.2

These statistics mean that smoking cessation services are an important part of the day-to-day remit of the primary care nurse. But just how much knowledge and experience is there among primary care and community nurses? The latest Nursing in Practice online survey, supported by an educational grant from Pfizer, aimed to gauge this, as well as how successful you feel you are in helping patients quit. And here are the results.

Background
A total of 65% of respondents stated that they have received training in smoking cessation. This included:

  • Local primary care trust (PCT) one-day course.
  • Brief intervention on smoking cessation and level 2 training course.
  • Two-day training course, no credit points.
  • PCT funded.
  • Two lectures as part of my nurse training.

When asked to state your confidence level in providing smoking cessation services for patients, responses were quite evenly spread, with the majority (36%) choosing a score of 4 out of 5 (5 being the most confident). Many people felt confident about the quality of the training they had received and said that they believe the support they provide benefits their patients.

A practice nurse in Cambridge commented: "I have done two comprehensive courses related to smoking cessation and feel this has given me the skills needed to help people make a quit attempt."

It appears from the survey results that a personal relationship with patients is a vital aspect of ensuring they feel supported enough to give up cigarettes, even if the nurse has not received any training. A nurse practitioner in Essex commented, "I do not consider myself to be an expert, but can provide motivational support for my patients."

It appears that when nurses feel supported by their colleagues, and have a good knowledge of the services to which they can refer patients, they feel more confident in treating them. This attitude is reflected in a comment by a practice nurse from Warwickshire, who feels that she has "good knowledge, and good working relationships with GPs and local reps for smoking cessation. Patients keep coming back."

Your patients
You told us that approximately 30% of the patients you see are affected by a smoking-related disease. Perhaps not surprisingly, a huge 83% of respondents said that they have seen an increase in the numbers of people wanting to give up smoking since it was banned in public places in England on 1 July 2007.
A total of 84.5% of respondents said that they raise the subject of stopping smoking at each visit with every patient who smokes. Sixteen percent said they raise the subject during the patient's annual screening/MOT check. Other responses to this question included:

  • "If it is raised as something they want to try and achieve, or if their health is being affected".
  • "When I feel it is appropriate".
  • "In one-to-ones with young people at school drop-in sessions".
  • "At each initial assessment".

The top two reasons given by patients for continuing to smoke were cited by respondents as stress (92.1%) and enjoyment (63.2%). Other reasons mentioned included fear of gaining weight on giving up, boredom and force of habit. The top two reasons for wanting to quit were health (90.5%) and money (67.6%). Other reasons cited included pressure from family members and social stigma.

The two most common difficulties people report experiencing when they give up smoking are cravings (74.9%) and irritability (69.9%). Again, weight gain was a quoted as an undesired side-effect of giving up smoking. It appears that increasing age is a factor in people wishing to give up smoking; the majority of people using smoking cessation services are over the age of 30.

Treatments
When asked which nicotine addiction treatment products are available for you to prescribe, most respondents stated patches (97.8%), with gum second and inhalators third. A total of 69.9% mentioned that they prescribe drugs such as Champix and Zyban (53.1%).

The nicotine addiction products that are most commonly requested by patients are patches, followed by Champix (see Table 1). Comments on the products prescribed by respondents included:

  • "I am recommending the patch more and more, plus another product (gum/lozenge especially)".
  • "Most people do not have a preconceived idea – most expect us to have an answer".
  • "Patients have heard of the success of Champix and are begining to request this more".

[[Tab 1 smoking]]

Patients can sometimes be reluctant to use recommended treatment products, and the majority of survey respondents feel this is because they prefer to do it on their own, without an aid.
Other reasons for people not using treatment products included the cost of the products, and also possible side-effects of treatment they have heard of. However, several respondents stated that lots of people they see are not reluctant to try products at all, and can come to the surgery with their own ideas about products they would like to try.

Support
With regard to the amount of support you are able to provide to someone going through a quit attempt, 83.2% of respondents said that they give as much time as the patient needs. Many professionals also responded that they are able to provide a 12-week programme of support. Most people stated that the percentage of patients receiving NHS treatment and support to stop smoking who manage to quit for a year or more is 0–20%. This demonstrates how hard it is to stop smoking for good, but also perhaps a lack of follow-up, with this information simply not being available to many primary and community care nurses involved in smoking cessation.

A healthcare assistant from Lancashire commented: "Most people say once they have stopped the NRT their cravings come back; they don't seem to understand that quitting smoking could affect them for a very long time and in stressful situations they reach for the fags straightaway."

A community matron based in London said, "My patients are elderly, it is not always possible to follow up on this over a long time as issues like death arise or they transfer to care homes."

A total of 86.6% of respondents are provided with NHS resources to assist in their work with smokers. Specifically, these include:

  • Stop smoking, start living booklets and leaflets.
  • Stop smoking leaflets provided by the PCT.

[[Tab 2 smoking]]

The majority of people (63.7%) also have a carbon monoxide monitor available to them during smoking cessation support. When nurses give patients contact details for relevant support groups and organisations, most respondents stated they would refer patients to the local PCT-funded stop smoking service.
When asked what you think is the hardest aspect of giving up smoking, 42% stated "changing the habit". Some more detailed comments include:

  • "For many older people all their friends still smoke so difficult for them to socialise without being tempted".
  • "Smoking is a group activity, it's a way of greeting a friend, opens conversations".
  • "Other people – they don't encourage but discourage".

[[Tab 3 smoking]]

Conclusion
Considering the breadth of knowledge primary and community nurses need to meet the planned and opportunistic needs of patients, this survey is very positive. There are some elements that need to be built upon; for example, nurses stated they would benefit from more training to improve their knowledge and skills. Nursing in Practice will address some of these issues in more detail in future editions.

Do the results of this report reflect your experiences of working with patients who smoke? If you would like to comment, please email the editor at: nip@campden.com

References
1. Action on Smoking and Health (ASH). Facts at a glance: smoking statistics. London: ASH; 2009. Available from: http://www.ash.org.uk/files/documents/ASH_93.pdf
2. Office for National Statistics (ONS). Smoking habits in Great Britain. London: ONS; 2008. Available from: http://www.statistics.gov.uk/cci/nugget.asp?id=313