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The smoke- free law: a new opportunity to help people quit

Jennifer Percival
RN RM RHV
Counsellor, Trainer, Author

Tobacco is a very unique consumer product. When taken as instructed by the manufacturers it kills half of all regular users. To compound this, for every smoker who dies, another 20 are living with the serious consequences of tobacco use. By the year 2020 tobacco use will account for one in three of all adult deaths in the world.(1)

Are you thinking: "Blah, blah, blah. Surely by now all smokers know the risks"?
It's true that over the past 10 years the combination of higher taxes, an advertising ban, new scientific evidence, hard-hitting public health education campaigns and the larger pack warnings have contributed to changing the mindset of the public. Despite this, 26% of people in the UK still smoke, the majority of whom are in the lower socioeconomic groups where tobacco use is a major contributor to health inequalities. So the battle is far from over and as a profession we must renew our efforts to tackle the death toll caused by tobacco use.
Finding a hook
When discussing "smoking" it's always useful to have a new angle. Smoking in enclosed public places and workplaces will be banned across the whole of the UK from 1 July 2007.(2) Until the law enters into force, restrictions on smoking will continue to vary from one place to another. Use this fact to start up your next conversation with a smoker. Ask: "What is happening about smoking in your workplace?", "Are there times now when you find it difficult to be an active smoker?"
Sarah Maloney, practice nurse from Streatham, says: "I'm really looking forward to the ban because so many younger smokers return to the habit when they're out socialising. In future they will be able to go out and not be tempted to relapse."

How to raise the issue
When raising the issue, you don't need to list the dangers. The health warnings on the packets are big and say scary things, such as: "Smoking kills", "Smokers die younger", "Smoking clogs the arteries and causes heart attacks and strokes", "Smoking causes fatal lung cancer", etc. Ask smokers what they think of the warnings on the pack. Are there any that bother them? Have they noticed any changes to their health while being a smoker? Approaching the subject from these new angles will get your patients thinking. 
Don't worry about offending smokers with your questions. Most smokers expect to be asked when they visit the NHS and the majority of smokers actually want to stop. It's important to address the issue because many people do not seek out professional help and try to go it alone. Unfortunately the success rate of unaided attempts is low due to the highly addictive nature of the drug nicotine.

How addictive is smoking?
Cigarettes look deceptively simple. The truth is that the manufactured cigarette is a highly engineered product that has been designed to deliver the exact amount of nicotine to ensure a smoker's continued dependence on tobacco.
Drug dependence is measured by the level of compulsion experienced by the user. Most smokers need to smoke on a daily basis and few believe that they could manage a whole day without smoking. Ask smokers how soon after waking they have their first cigarette of the day. We know 15% light up within five minutes of waking, and 46% smoke within the first half hour of the day. Eighty-one percent of smokers who smoke 20 or more cigarettes a day say that they would find it difficult to go a whole day without smoking.(3)
A new graphic government campaign has attempted to show the seriousness of addiction through a series of poster and TV ads, picturing a large fishhook pulling at the mouths of smokers. You could try asking your patients what they think about the ads, do they put them off smoking? Alternatively, start a conversation about nicotine addiction quoting the ads and ask how soon after waking they light their first cigarette. Follow up with information on the range of NHS services set up to help smokers and ask if they'd be interested in stopping.

Helping people make the decision to change
While breaking the physical addiction to nicotine is hard, for many smokers breaking the habit - the psychological addiction - can be much harder. Smoking has often become a deeply ingrained habit - an integral part of most activities. This is why smokers are usually skilled at justifying their continuation of the habit. Here are some examples of ways to respond to the excuses:

"Smoking helps me stay thin"
Acknowledge this, and explain that weight gain is caused by a change in the body's metabolism and because food tastes better when people stop smoking. Explain that the risks of continuing to smoke far outweigh those from weight gain. Ask if they're planning to be a lifelong smoker? If they say "no" ask what would have to happen for them to consider stopping.
"Smoking helps me when I'm stressed"
This is one of the most common reasons people give for continuing to smoke or relapsing. The reality is that smokers generally experience higher levels of stress than nonsmokers. After stopping the level of stress in exsmokers drops noticeably. People are likely to experience mood swings and be irritable as the result of nicotine withdrawal. Using nicotine replacement therapy helps this symptom.

"I know people who have got cancer after they stopped smoking"
Stopping smoking at any age increases a person's life expectancy. It is always worth stopping smoking even if you're already ill. Sadly, in some people, that damage only becomes apparent in the early years after stopping. Ask how it would affect them if they became ill.

"I only smoke cigars/pipe"
There is no safe form of tobacco use. Switching to cigars or a pipe gives you the same risk of developing cancer, so don't kid yourself that they are better for you. Ask what is stopping them from quitting altogether.

"I've switched to 'light'/'low-tar' cigarettes"
So called "light" or "low-tar" cigarettes are no less harmful than other cigarettes. In fact the UK banned the terms "light", "mild", "low-tar" because they gave a misleading impression that these products were less harmful than other cigarettes. Ask why they switched brands and what they hoped to gain. 

"I'm already ill - the damage is done"
Reassure them that regardless of their condition most medical treatments work more effectively when someone stops smoking. Explain that as soon as they stop smoking their blood carries more oxygen, which will help the healing process.

"I failed last time. I don't want to put myself through all that again"
Explain that most people need to make several attempts before they learn how to break the habit of smoking. Ask what worked last time and what they would need to do differently to succeed in the long term. Suggest that they avoid situations in the first week where they might be tempted. Encourage them to use the NHS stop smoking services and a treatment product.

"I cannot cope with the withdrawal symptoms"
Physical withdrawal symptoms are likely to start a few hours after they stop smoking, peak within three or four days, then gradually decrease and fade away within three or four weeks. National guidelines require health professionals to advise all smokers to use a treatment product to assist their quit attempt.

"I am waiting for my life to calm down"
There will never be a perfect day to quit smoking. If some unexpected challenges occur on the day you choose to stop, either decide on another day or find a way to use them to your advantage. Getting support is a very vital part of the process so encourage them to buddy up with a friend or join an NHS stop smoke group.

The process of stopping
Stopping smoking is a process: first the person has to decide that they want to and then they have to do it. No two smokers are the same and it's important to realise that there is no one perfect method. If it's working, support them to continue. In essence smokers need to have a good reason, personal support, a date to quit and be prepared to stick to a 8-12 week course of treatment to succeed.

Conclusion
Helping people to stop smoking should be on everyone's agenda. Investing in smoking cessation can save the NHS money and time and ultimately people's lives.  With the government's plans to make all public places smoke-free, and the current media attention on the topic, there has never been a better time to raise the issue of stopping with each and every smoker.

References

  1. WHO. Tobacco free initiative (TFI). Geneva: WHO; 2004.
  2. NHS. Smokefree. Available from: http://www.smokefreeengland.co.uk
  3. Royal College of Physicians. Nicotine addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. London: RCP; 2000.