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Helping patients to stop smoking?



Key learning points:

  • Nurses in primary care have a duty to provide brief advice and information to people who smoke, and should be able to refer them to specialist services
  • There are three main types of medicine available on the NHS for people who want to stop smoking: nicotine replacement therapy (via gum, patches and lozenges), bupropion and varenicline
  • While it’s better to stop smoking altogether, the NHS can also support people who want to cut down how much they smoke, or quit for a period of time

Tobacco smoking is among the top causes of avoidable disease and death in the entire world,1 One of the best things a nurse can do for a patient’s health is to help them to stop smoking. In addition, primary care nurses have a specific obligation to provide advice to people who smoke.2
Latest figures show that 19% of UK adults are smokers.3 While this is down significantly from the 1970s, the numbers have not declined much in the past 10 years. Young people aged 25 to 34 are most likely to smoke, although older people who smoke are heavier tobacco users.
This article will look at different types of smoking cessation treatment and how nurses can use it to help patients quit or cut down on their smoking.
Nurses need to be aware of three guidelines published by the National Institute for Clinical and Health Excellence (NICE) relating to smoking cessation:

  • PH1, published in 2006, which recommends brief interventions to support patients to stop smoking.2
  • PH10, published in 2008 and updated in 2013, which recommends stop smoking services, including provision of medicines.4
  • PH45, published in 2013, which recommends ways to help people who want to cut down but are not ready to stop smoking altogether.5

Brief interventions
NICE is clear that nurses have a duty to provide brief interventions to help people stop smoking: ‘Nurses in primary and community care should advise everyone who smokes to stop and refer them to an intensive support service (for example, NHS stop smoking services).’2
All health professionals in primary care should be trained to give brief advice on stopping tobacco use, and should have contact with their local NHS stop smoking service, and know how to refer people to it.4
NICE says that nurses or others in primary care should ask people if they smoke and record their answer. Everyone who smokes should be asked how interested they are in quitting. People who want to quit should be offered help, and people who are not ready to quit should be asked to consider the possibility and encouraged to seek help in the future.
However, the guideline authors acknowledge that there may be circumstances where a person’s situation makes this inappropriate – for example, if they are in the final stages of a terminal illness.
People who decline a referral to NHS stop smoking services can be offered additional support, including medicines, in primary care (see below). The decision not to quit should be recorded and the topic revisited once a year.
Brief interventions can include offering self-help materials,4 such as NHS leaflets, information on NHS websites or mobile apps such as the NHS Smokefree app (see the NHS Choices stop smoking pages for more information: nhs.uk/livewell/smoking/Pages/stopsmokingnewhome.aspx)

Stop smoking services
NICE Guideline PH10 outlines the services that can be offered as part of NHS treatment. These include:4

  • Brief interventions.
  • Individual or group behavioural counselling.
  • Medicines (NRT, bupropion and varenicline).
  • Self-help materials in written or digital formats.
  • Telephone counselling.

Primary care nurses can provide brief interventions and self-help materials. Specially trained nurses can also provide counselling and medicines.
Other treatments – including some popular ones like acupuncture and hypnotherapy – don’t have enough evidence to be recommended by NICE. While ‘quitting should always be encouraged,’ the guideline authors say: ‘Treatments that have not been rigorously evaluated and found to be effective should not be available through the NHS.’4
Counselling, whether individual, group or telephone, should be provided by trained NHS stop smoking counsellors. Primary care nurses who have had this training can run counselling sessions themselves, and provide self-help materials.
Medicines can be prescribed only by nurses who have qualified in medicines prescription, but primary care nurses can advise people on the types of medicines available to help them stop, including NRT products that can be bought from pharmacies.
The guideline states that NRT, bupropion and varenicline can be offered to people who intend to stop smoking, as appropriate. Bupropion and varenicline are not offered to patients under 18, or to pregnant or breastfeeding women. NRT, however, can be offered to these groups (and to people with unstable heart conditions), after discussion of the risks. People with unstable heart conditions may be able to take varenicline or bupropion if the prescribing clinician judges the risks and benefits make it worthwhile.4
Nurses prescribing these treatments should normally do so after a smoker has made a commitment to stop smoking on or before a particular date (but see ‘harm reduction’ below). The prescription should be sufficient to last until just two weeks after the target stop date.
The guideline says that NRT, varenicline and bupropion should not be combined, but that a combination of different forms of NRT (eg long-acting patches plus a short-acting type such as gum or inhalator) can be offered to people who smoke heavily, or who have found in the past that single forms of NRT don’t work for them.
The guideline does not recommend any particular type of treatment. It says: ‘Do not favour one medication over another. The clinician and patient should choose the one that seems most likely to succeed.’ Things to bear in mind include:

  • Whether the patient has been referred to stop smoking services.
  • Contraindications and possible side-effects.
  • The patient’s own preferences.
  • Previous use of smoking cessation aids.4

Smoking cessation for special groups
Pregnant women
Women who smoke in pregnancy are more likely to miscarry, and to have problems during pregnancy and childbirth, including ectopic pregnancy, bleeding during pregnancy, premature detachment of the placenta and premature rupture of the membranes. Their babies are also at increased risk of health problems, including a low birth weight and sudden infant death syndrome.4 In 2014 in the UK, just over one in 10 babies were born to a mother who smoked during pregnancy.2
Because of this, women who smoke in pregnancy, or who smoke and are trying to get pregnant, are targeted for advice on how to stop. NICE Guideline PH10 says that healthcare professionals who come into contact with women in these situations, including midwives, health visitors and nurses in occupational health centres, should ‘At the first contact, discuss her smoking status, provide information about the risks of smoking to the unborn child and the hazards of exposure to secondhand smoke’.4
Nurses should take the opportunity to discuss any concerns about stopping smoking, and offer personalised advice and support to quit. ‘Encourage pregnant women to use local NHS stop smoking services and the NHS pregnancy smoking helpline by providing details on when, where and how to access them. Consider visiting pregnant women at home if it is difficult for them to attend specialist services.’4
The woman’s smoking status should be monitored during pregnancy and after the birth, and she should be provided with advice, support and encouragement throughout. ‘If a woman expresses a clear wish to receive NRT, use professional judgment when deciding whether to offer a prescription,’ the guideline says. While NRT may affect the unborn baby, it is thought to be less harmful than smoking tobacco.
Pregnant women from poorer backgrounds, and those aged 20 or under, may need additional support to give up smoking, the guideline says.

Young people
Young people are at particular risk from smoking, not just because of the damage it can do to growing bodies, but because starting smoking in adolescence can lead to a lifetime of tobacco use. Figures show 20% of people aged 16 to 19 in the UK smoke.6
People aged 12 to 17 should be offered information, advice and support on how to stop smoking, and should be encouraged to use local stop smoking services, guideline PH10 says. Where people aged 12 to 17 show signs of nicotine dependence (for example, heavy smoking or smoking shortly after waking each day), they may need NRT. Healthcare professionals should use their clinical judgment to decide whether to offer this. People under 18 should be offered NRT only within a supervised treatment regime.4

Harm reduction when patients are not ready to quit completely
Some people may want to stop smoking and worry about the health impacts, but not feel ready to quit completely. While stopping is the best way to reduce harm from smoking, cutting down is also beneficial and may help people prepare to quit in the future.
NICE Guideline PH45 looks at how healthcare professionals can help people in this situation, and what treatments might be suitable. It says nurses in primary care should identify people who smoke and advise them to stop in one step as the best approach. When people are unwilling or unable to do so, nurses can ask whether they would like to consider harm reduction. There are four main approaches that are suitable for different situations:5

  • Stopping smoking, but using one or more licensed NRT products as long as they need.
  • Cutting down the number of cigarettes smoked, as preparation for stopping, with or without use of NRT for as long as needed.
  • Cutting down the number of cigarettes smoked, with or without use of NRT, without necessarily intending to stop.
  • Temporary abstinence, with or without use of NRT as long as needed. This might be to recover from an illness, prepare for an operation or for some other specific reason.

What about e-cigarettes?
Nicotine-containing products typically available on NHS prescription include inhalators, chewing gum, lozenges, nasal spray and patches. These types of NRT provide a low dose of nicotine, intended to reduce nicotine cravings while people cut down or stop smoking. They don’t usually provide the hit of nicotine that people get from smoking tobacco.
Electronic or e-cigarettes provide variable doses of nicotine, in a puff of vapour that is taken into the lungs. No tobacco is involved, just a nicotine-containing liquid that is vapourised by a heating element. E-cigarettes provide a hit similar to that felt when smoking a cigarette, which might be one reason why they have become more popular among people wanting to reduce or give up smoking, compared to traditional NRT products. Use of e-cigarettes is often called vaping.7
Until recently, no e-cigarettes were licensed as NRT products. There were concerns about the relatively unregulated status of e-cigarettes, and possible variability in quality of the devices and the nicotine liquid. However, in January 2016, the Medicines and Healthcare Products Regulatory Agency approved the use of British American Tobacco’s e-cigarette e-Voke, meaning it can be prescribed on the NHS as a smoking cessation aid.8 Guidance on use of e-cigarettes for smoking cessation is due to be issued by NICE in November 2017. The new guideline, Smoking Cessation Interventions and Services, will update information about all types of smoking cessation treatments, as well as including an assessment of whether e-cigarettes meet the NICE threshold of efficacy and value for money. Until then, e-cigarettes are not expected to be routinely prescribed on the NHS.9

Conclusion
Primary care nurses see a wide cross-section of the population every day, putting them in a good position to ask about smoking status, offer advice and self-help materials, and, where appropriate, specialist services.

References
1. World Health Organisation 2016. Tobacco Fact Sheet.who.int/mediacentre/factsheets/fs339/en/ (accessed 20 September 2016).
2. Office for National Statistics. Adult smoking habits in Great Britain: 2014. ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2014 (accessed 20 September 2016).
3. NICE. Smoking: brief interventions and referrals, 2006. nice.org.uk/guidance/ph1 (accessed 20 September 2016).
4. NICE. Stop smoking services, 2013. nice.org.uk/guidance/ph10 (accessed 20 September 2016).
5. NICE. Smoking: harm reduction, 2013. nice.org.uk/guidance/ph45 (accessed 20 September 2016).
6. Office for National Statistics. Smoking in young people, 2016. ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/drugusealcoholandsmoking/adhocs/005388smokinginyoungadults (accessed 20 September 2016).
7. Do electronic cigarettes help with smoking cessation? Drug and Therapeutics Bulletin 2014;52(11);126-129. DOI:10.1136/dtb.2014.11.0288
8. Pharmaceutical Times. MHRA licenses e-cigarette as a medicine. pharmatimes.com/news/mhra_licenses_e-cigarette_as_a_medicine_1020697 (accessed 20 September 2016).
9. NICE. Smoking Cessation Interventions and Services GID-PHG94, 2016. nice.org.uk/guidance/indevelopment/gid-phg94] (accessed 20 September 2016).