Key learning points
- Smoking is the leading cause of preventable disease and premature death in the UK
- The majority of smokers find it difficult to quit without support
- Staff in general practice can empower and support patients to succeed
Current levels of smoking in the UK
Tobacco use remains the leading cause of preventable death and disease in the UK, accounting for over one-third of respiratory deaths, over one-quarter of cancer deaths and about one-seventh of cardiovascular disease deaths.1
Thanks to the enormous amount of work done by the NHS, smoking prevalence has dropped. Currently, fewer than one adult in five (17%) in the UK smokes: 19% of men and 15% of women. The problem has not gone away, however, as there are still 9.1 million adult smokers in the UK (8.7 million in Great Britain) and statistically, 50% of all regular smokers die prematurely.2
Do people want to give up smoking?
Findings from the Smoking Toolkit Study (STS)3 (which conducts monthly surveys of people in England aged 16+) show that over two-thirds of smokers report wanting to stop, with 32% intending to make an attempt soon.
The methods smokers commonly use to quit are trying it alone (willpower), buying nicotine replacement therapy (NRT) over the counter or taking a stop-smoking medicine provided on prescription. Disappointingly, the most effective method – getting ongoing support from an NHS-trained specialist and taking a course of prescribed medication – is used by only 5% of people wanting to stop smoking.
Providing a stop-smoking service in general practice
Most GP practices already have trained staff who are able to provide a stop-smoking service. Nationally, these services have proven to be highly cost-effective, and have reduced the health inequalities caused by smoking.
As most smokers see their GP at least once a year, it’s important that primary care staff continue to give a clear message that using their professional support is the single best way for a smoker to end their addiction to tobacco.
The people who have the highest smoking prevalence include routine and manual workers, people with mental health disorders (including alcohol and substance use), prisoners, LGBT communities, the homeless and certain black and minority ethnic groups. Patients from these groups often have a strong desire to quit but may need more intensive support.4
Across England, budget cuts by local authorities have resulted in the reduction or closure of many of the local NHS stop-smoking services. Consequently, more smokers are turning to their general practice or pharmacist for help to quit. With more cuts taking place this year, routinely offering stop-smoking support to every smoker is vital.
Staff in general practice will have already seen many patients who demonstrate a strong desire to quit and may have observed that despite professional help, they relapse. It’s important to remember that addiction to nicotine is stronger than addiction to heroin. Nicotine addiction is classified as a chronic relapsing dependence syndrome, reinforced by sensory, behavioural and social conditioning and entrenched by a powerful withdrawal syndrome.5 But don’t let a patient’s past failures deter you from offering further support. Most smokers make several attempts to quit before succeeding and you can help them learn from their lapses.
How to raise the issue in 30 seconds
Regardless of any expressed desire to stop, all smokers should be informed that the best way to stop smoking is through a combination of behavioural support and medication and that treatment can be offered immediately.
The National Centre for Smoking Cessation and Training (NCSCT) has put together a very brief advice model,6 which satisfies Quality and Outcomes Framework (QOF) criteria and can be offered during most consultations (see left). A video showing how to use this module is on the ncsct.co.uk website.6
The three elements are:
- Establishing and recording smoking status – ask.
- Advising on the best ways of stopping – advise.
- Offering a referral to help them quit – act.
Best practice guidance
Evidence from The National Institute for Health and Care Excellence (NICE)7 has shown that a combination of behavioural support from a trained stop-smoking practitioner and licensed pharmacotherapy will significantly increase a smoker’s chances of stopping. It recommends a person wishing to give up tobacco uses an abrupt approach as this is the most effective method.
Current licensed treatments
The stop-smoking medicines currently licensed are NRT, bupropion (Zyban) and varenicline (Champix). Varenicline and combination NRT offer smokers the best chances of quitting and should be available as first-line treatments unless clinically contraindicated.
NRT is safe and effective. When provided by a healthcare professional and used without additional behavioural support, it approximately doubles the chances of long-term abstinence. There are eight types: patch (24-hour and 16-hour), gum, lozenge (and mini-lozenge), microtab, nasal spray, mouth spray, oral strip and inhalator.
Using a combination of NRT products has been shown to have an advantage over using a single product, increasing the chances of quitting by up to 35%. It is recommended to prescribe a nicotine patch to provide a steady level of nicotine alongside a second faster-acting product to help your patient cope with strong cravings or urges to smoke.8
The licensing of varenicline has recently been changed and as a result, the black triangle symbol has been removed. Results from a large-scale clinical trial demonstrated that the use of varenicline in patients with or without a history of psychiatric disorder was not associated with a significantly increased risk of serious neuropsychiatric adverse events compared with placebo.9
Working with a patient who wants to stop smoking
- Review their past experiences of quitting – what helped, what hindered?
- Record their carbon monoxide level.
- Confirm the date they wish to stop smoking completely.
- Discuss their nicotine withdrawal symptoms and cravings and offer treatment to help them manage these symptoms.
- Provide an initial one-week supply.
- Check their expectations of your support and the medication.
- Ask about their support network and address any potential high-risk situations.
- Make a follow-up appointment to assess progress and check suitability of medication prescribed.
What can general practice staff do to encourage more people to give up?
Many surgeries routinely offer a stop-smoking drop-in session to patients with long-term conditions. A carbon monoxide test is taken and the results explained alongside the benefits of quitting.
A recent study10 found many smokers underestimated their risk of illness due to smoking. During the trial, they sent letters to smokers inviting them to attend a stop-smoking taster session, where each individual was provided with personalised advice on their risks. Some 17% of patients who received a personalised letter attended the first session at the stop-smoking service within six months, compared with 9% of those who had a routine referral letter. Those that attended were twice as likely to seek help to quit.
The researchers said motivating smokers to try to quit is highly relevant, especially when combined with a reassuring message that support is available. They estimate that the intervention would be a cost-effective use of NHS resources – and sending a personalised letter to patients could improve uptake of stop-smoking services.
Practice nurses can also encourage people to ‘stop before their op’. It’s worth taking the time to advise patients who are waiting for surgery of the benefits of quitting smoking before their admission to hospital. Explain that stopping reduces their risk of complications, improves wound healing time, decreases their length of hospital stay and possible post-operative complications.
Working with Electronic Cigarette users
Over the past 10 years, a large range of unlicensed, nicotine-containing products (originally called e-cigarettes) have become popular. These devices are growing more sophisticated and users call themselves vapers. Growth in vaping has been accompanied by a reduction in use of licensed nicotine products and prescription medication.
An independent review by Public Health England11 concluded that e-cigarettes are significantly less harmful than tobacco and have the potential to help smokers quit. While vaping may not be 100% safe, most of the chemicals causing smoking-related disease are absent and those chemicals that are present pose limited danger. The review noted that although there has been a shift towards the inaccurate perception that e-cigarettes or vaping devices are as harmful as cigarettes, the current expert opinion is that using them is around 95% safer than smoking.
A Cochrane Review12 concluded that e-cigarettes can help people to quit smoking and may be contributing to the decline in smoking. They also found some evidence to suggest that e-cigarette use can lead to abstinence among some smokers who had not intended to quit.
The NCSCT recommends that all practitioners should be open to e-cigarette use among smokers trying to quit, particularly if they have tried other methods and failed. It has issued guidance on ways to support people choosing to quit using their own vaping device with or without an NRT product.13
The use of vaping devices by pregnant women has also been looked at and the conclusion is that while licensed nicotine replacement products are the recommended option, if a pregnant woman chooses to use an e-cigarette to help her stay smoke free, she should not be discouraged.14
- NHS national website smokefree.nhs.uk
- NHS Stop Smoking Helpline for patients 0800 022 4332
- National Centre for Smoking Cessation and Training, established by the Department of Health in 2008 to standardise training for those providing support for and delivering stop smoking services. Find the full range of training at ncsct.co.uk/pub_training.php.
- Smoking Toolkit Study smokinginengland.info
1 Fact Sheets, Action on Smoking and Helath, ash.org.uk/information/facts-and-stats/fact-sheets.
2 Health and Social Care Information Centre. Statistics on Smoking, England May 2016.
3 Smoking Toolkit Study smokinginengland.info (accessed May 2017).
4 Bauld L, Judge K, Platt S. Assessing the impact of smoking cessation services on reducing health inequalities in England: observational study. Tob Control 2007;16:400-4.
5 Royal College of Physicians. Nicotine Addiction in Britain: A Report of the Tobacco Advisory Group of The Royal College of Physicians 2000.
6 National Centre for Smoking Cessation and Training. Very Brief Advice on Smoking training module ncsct.org.uk.
7 National Institute for Health and Care Excellence. Smoking Cessation Services (PH10). NICE 2008: publications.nice.org.uk/smoking-cessation-services-ph10 3.
8 Stead LF, Perera R, Bullen C et al. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2008;1.
9 Anthenelli RM, Benowitz NL, West R et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomized, placebo-controlled clinical trial. Lancet 2016 19:e1-e14.
10 Gilbert H, Sutton S, Morris R. Effectiveness of personalised risk information and taster sessions to increase the uptake of smoking cessation services (Start2quit): a randomised controlled trial. Lancet 2017;389:823-33. Open access funded by Department of Health UK.
11 E-cigarettes: an evidence update. Report commissioned by Public Health England 2015.
12 McRobbie H, Bullen C, Hartmann-Boyce J et al. Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews 2014;12 (Cd010216).
13 National Centre for Smoking Cessation and Training. Electronic cigarettes: A briefing for stop smoking services 2016 ncsct.org.uk/usr/pub/electronic_cigarettes._A_briefing_for_stop_smoking_services.pdf.
14 National Centre for Smoking Cessation and Training. Smoking Cessation: A briefing for midwifery staff 2016 ncsct.org.uk/usr/pub/midwifery_briefing_%20v3.pdf (accessed May 2017).