Smoking cessation 1: interventions to support attempts at quitting

This article, the first in a five-part series on the nurse’s role in smoking cessation, looks at the effectiveness of brief interventions and referral to stop smoking services

Abstract

Advising patients on how to stop smoking is part of a nurse’s role. Patients can be resistant to the intervention and this article, the first of five on smoking cessation, offers insights on the importance of creating optimism about stopping smoking. It describes how to give very brief advice to encourage patients to make a life-changing decision to quit, the role of stop-smoking services, and the use of products and behavioural interventions that nurses can use to help reduce smoking prevalence and improve patients’ health.

Citation: Ross L (2020) Smoking cessation 1: interventions to support attempts at quitting. Nursing Times [online]; 116: 3, 30-33.

Author: Louise Ross is freelance clinical consultant, National Centre for Smoking Cessation and Training.

  • This article has been double-blind peer reviewed
  • Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)

Introduction

Smoking causes 200 premature deaths in the UK every day (Department of Health, 2017). An estimated 15.5%of adults in the UK smoke (DH, 2017) and, although this represents a big improvement from 1974, when 46% of the adult population smoked (Action on Smoking and Health (ASH), 2018), it shows how much more there is to do to reduce the number of people who smoke.

The outlook for lifelong smokers is not as positive as that for the general population; they are more likely than non smokers to develop chronic respiratory disease, a serious heart condition or cancer. Such patients face the challenge of living with their smoking-related condition, and the ever-present limitation of disability that has been caused by their illness can become their identity.

Nurses are ideally placed to intervene to help people stop smoking and change their life stories. As part of creating a smoke-free NHS, the DH’s (2017) tobacco control plan for England urges NHS trusts to make training available for all health professionals on how to help patients to quit smoking.

Guidance published by the National Institute for Health and Care Excellence recommends that all patients who smoke are:

  • Advised and encouraged to stop;
  • Given the support they need (NICE, 2018; NICE, 2013).

The Royal College of Physicians (2018) emphasises the need to address smoking in patients using secondary care as well as those in primary care, stating “Our NHS should be delivering default, opt-out, systematic interventions for all smokers at the point of service contact”. However, the British Thoracic Society’s (2016) smoking-cessation audit report showed that, on admission to hospital, around 19 in 20 patients were never asked more than a cursory question about smoking. Assessments were completed for these patients but the intervention that should have happened – brief advice on smoking cessation to patients who smoked – was absent. Healthcare workers should be trained to give very brief advice (VBA) (RCP, 2018).

Very brief advice

NICE (2018) guidance recommends that primary and community care practitioners give VBA that takes less than 30 seconds to deliver to patients who smoke. VBA uses the AAA framework:

  • Ask all patients if they smoke;
  • Advise patients how to stop smoking and to use specialist support;
  • Act – provide a referral to stop-smoking services or offer behavioural support and drug treatment.

However, a survey undertaken by Rosenberg et al (2019) for Cancer Research UK found that only around half of primary and community health practitioners reported frequently completing VBA. Approximately 40% of practitioners perceived that patients were unreceptive to smoking-cessation advice and 15% were concerned about negative patient reactions.

The National Centre for Smoking Cessation and Training (NCSCT) includes an evidence-based VBA training module as part of its e-learning and other resources for health professionals; this has been endorsed by the RCN.

VBA is a ‘must do’ for nurses as it shows the best way to raise the subject with patients without getting into a circular, frustrating discussion. Saving time, as well as being effective, it is recommended for all patients who smoke, no matter their age or health status, whether they have never tried to quit before or have rejected the idea every time it has been raised.

Nurses should not assume that patients who have been previously unreceptive to stop-smoking advice will always be so, as shown by the Stages of Change model (Fig 1). People’s circumstances change, a friend stopping smoking, a new baby in the family, a bad chest infection or being in a smoke-free hospital, for example, may be the critical moment when a person says, “Yes, OK, I’ll give quitting a go”.

In my experience, most people remain defensive in the face of uncomfortable pressure to quit. Clinical experience suggests that the first question, “Do you smoke?”, can be the most difficult for patients to answer because of feelings of guilt and embarrassment – especially if their presenting illness is smoking related.

Once a patient’s smoking status has been established, a nurse can swiftly turn the intervention to the good news: “Did you know that the most-effective way of stopping smoking is with specialist help – a combination of behavioural support and effective stop-smoking products?” This should be swiftly followed with an offer of support: “Would you like me to refer you to your local stop-smoking service?”

Stop-smoking services

Patients often recognise that they need some help, but the effort of finding out where and how to access that help can be a significant obstacle. Nudging them into accepting support by offering a seamless pathway to the local stop-smoking service will increase their chances of a successful quit. It is also helpful if nurses have knowledge of what happens in a stop-smoking clinic – which is outlined in Box 1 – so they can answer patients’ questions.

Box 1. Stop-smoking services

Waiting times for stop-smoking services are usually one or two weeks at most. The idea of a confessional-style group can put people off, but most sessions are in fact held on a one to one basis. Service users see a trained practitioner, who assesses their individual needs and establishes a plan of action. As well as prescribing stop-smoking products that meet the person’s needs and preferences, the practitioner uses their specialist skills to motivate and coach the person, which is important to the intervention’s success. Sessions are weekly, at least for the first few weeks, then taper until the end of treatment at around 8-12 weeks.

At each appointment, the practitioner checks the person’s carbon monoxide (CO) levels; CO is the poisonous gas inhaled in the smoke from a burning cigarette, which together with the tar causes severe health harms, including cancer, stroke, heart disease and respiratory disease. Measuring a person’s CO levels confirms whether they have smoked recently and can motivate them as it can show that CO levels are down to that of a non-smoker. Levels usually drop about 12 hours after stopping smoking but this depends on how much the person has smoked.

Unfortunately, some areas of the country have decommissioned stop-smoking services, but nurses:

  • Can check the referral route with their manager;
  • Should encourage patients to see their GP or pharmacist if there is no specialist service available.

Some nurses may be in a position to offer advice and products straight away, but this depends on the setting. They should also be aware that patients need continuing support to achieve a successful outcome.

Smoking-cessation medicines

Stop-smoking products and medicines include:

  • Nicotine replacement therapy (NRT);
  • E-cigarettes (vapes);
  • Varenicline (Champix);
  • Bupropion (Zyban)

All have a good efficacy profile (Hajek et al, 2019), but combining treatment with specialist support has been shown to give people the best chance of stopping smoking (Stead et al, 2016).

Varenicline and bupropion are prescription-only medicines that are nicotine-free and designed to reduce nicotine cravings and side-effects. Practitioners should provide advice and support on their use and, ideally, monitor any side-effects that may deter service users from continuing the course of treatment.

NRT can also have minor side-effects, but one issue is that people often skimp on the dose because of concerns about using nicotine and becoming addicted to another substance. Nurses should encourage patients to use NRT as often as recommended, as this will help them overcome their cravings. ‘On the hour, every hour’ is the advice for oral products such as gum and lozenges, while patches need changing every day.

Vaping

Safety questions have been raised about vaping but it remains the most-popular and most-effective way of stopping smoking in the UK (Dockrell, 2018). At least one NHS trust has opened a vape shop on its sites to help smokers – be they patients, staff or visitors – to comply with the trust’s smoke-free policy (Press Association, 2019).

Vaping products, or e-cigarettes, produce vapour from nicotine dissolved in liquid, propylene glycol or vegetable glycerine, but do not contain tobacco. People who smoke tobacco become dependent on nicotine, but die from the tar and carbon monoxide in the tobacco, so using a device that provides clean nicotine with no smoke is similar to using NRT.

The RCN acknowledges that, “a common question is whether electronic cigarettes should be recommended by healthcare professionals”. Current guidance – outlined in Box 2 – states that vaping is significantly less harmful than smoking and it has, therefore, been endorsed by Public Health England (PHE), ASH, Cancer Research UK, the Royal College of Physicians, the NCSCT and other bodies as an intervention to stop smoking. In light of this guidance, nurses should be encouraging of any patient who shows an interest in vaping to stop smoking (PHE, 2018).

Box 2. Guidance on vaping/e-cigarettes

  • Cancer Research UK the charity points to growing evidence that e-cigarettes can help people move away from smoking tobacco, but says initial indications suggest success rates are higher when vaping is used alongside support from stop smoking services
  • Public Health England – the body says people who smoke should consider switching completely to nicotine-containing e-cigarettes, and people who vape should stop smoking altogether (McNeill et al, 2019; McNeill et al, 2018). An evidence update, reviewed by leading independent tobacco experts, suggests e-cigarettes help people to stop smoking and contribute to 50,000-70,000 additional quits in England per year (McNeill et al, 2019).
  • National Institute for Health and Care Excellence – its guidance says health professionals should not discourage using e-cigarettes as an aid to quit smoking, but should provide people with the appropriate information and advice (NICE, 2018). In 2016, the British Thoracic Society stated that only one in four (27%) health practitioners in primary care reported frequently providing patients with advice about e-cigarettes as a tool to quit
  • Royal College of General Practitioners and Cancer Research UK a useful podcast by these two organisations explains more about the untapped potential of vaping to help people stop smoking
  • Royal College of Nursing its smoking-cessation guidance states that vaping is not risk-free, but is thought to carry a fraction of the risk of smoking, and that people who smoke tobacco have “at least 50% risk of dying from a smoking related disease, often in middle age”

Behavioural interventions

It is helpful for nurses to look deeper into the mindset of people who smoke (Box 3). For stop-smoking advice to be effective, nurses need to give patients hope and optimism that they can quit and that it will be worth it (ASH, 2019)

Box 3. Understanding the mindset of people who smoke

Most people who smoke start when they are children or teenagers, particularly if they have friends or parents who smoke. In the most disadvantaged areas of the country, young people are more likely to grow up among adults who smoke, thereby leading them to try it; they then become dependent on smoking at a young age (Leonardi-Bee et al, 2011). Poor education, mental health problems and unemployment also increase the likelihood of people smoking and it becoming ingrained in that person’s life (ASH, 2019b).

People who smoke often feel that a cigarette eases stress, even though it actually increases the heart rate and raises blood pressure. Smoking for someone who is dependent on tobacco usually becomes a comforter, a calming influence, a stress reliever and a mood enhancer. The knowledge that smoking is likely to cause disability and an early death may not be a deterrent, as smoking behaviour is maintained by the reinforcing properties of nicotine in a way that is pleasurable for the smoker – concern about any long-term damage is not sufficient for the person to make a change (West, 2017).

A valuable intervention promoted in ASH’s (2019a) report, The End of Smoking, is to encourage patients identified as smokers to try to quit at least once a year. The report highlights that, “currently in England, only 30% of smokers make at least one quit attempt every year”, and “only 5% of smokers successfully quit each year”. It goes on to state that it will take until 2043 to reduce smoking prevalence to 5%, but indicates that “if 50% of smokers made an annual quit attempt, we could get to 5% smoking prevalence by 2029”.

Asking patients the simple question, “Have you made your annual quit attempt yet?” acknowledges the difficulty of the task, but normalises the idea that it is worthwhile to keep on trying (ASH, 2019). As ASH (2019) also points out: “Every successful quit begins with a serious quit attempt”. Whether the question is asked in primary or acute care, mental health, domiciliary care, maternity, occupational health or any other setting, it could trigger a change of behaviour in patients that lasts a lifetime – and a longer, healthier lifetime at that.

What to tell a person with cancer

Patients with cancer – particularly if their cancer is smoking related – may see no point in changing their smoking habit once the damage is done. Distraught at their diagnosis, they may feel that they might as well keep using cigarettes, both as a stress-reliever and in defiance of fate. It is important that nurses caring for these patients advise them that quitting is likely to make the side-effects from their cancer treatment more tolerable (Peppone et al, 2011).

There is also growing evidence that stopping smoking during treatment for some cancers increases survival rates (Zeng et al, 2019). Even when treatment only extends life, rather than providing a cure, stopping smoking can add months of life and give patients more time with their loved ones (Gemine et al, 2018). If patients are going through the arduous process of chemotherapy or radiotherapy, endless appointments and unpleasant side-effects, there may be a strong incentive to quit smoking to give the treatment the best chance of success.

Reaping the benefits

An added incentive for someone who has chosen to quit smoking is that the health benefits start soon after that last cigarette. Many treatments take weeks to show improvements, but within a day of stopping smoking, an individual’s blood pressure and pulse start to drop and blood carbon monoxide levels return to normal. Other health improvements follow, including less shortness of breath and more energy. Practitioners in stop-smoking clinics often point out how much better people’s skin looks around the fourth week of their treatment.

Vital to this is the ‘not another puff’ rule. Patients may assure the nurse that they are cutting down and, although they should be congratulated on their efforts, nurses need to impress on them that the only way to bring true benefits is to stop completely. Smoking fewer cigarettes generally means each cigarette is smoked harder and right down to the end, and the desire for another one becomes even stronger. If it can be conveyed to patients confidently, but sympathetically, that stopping completely is the only way to eliminate ongoing harm to the body, they will be able to draw on these words when the going gets tough. This should be coupled with reassurance that millions of people have quit and they can too.

Nurses who smoke

When I trained as a nurse, most nurses smoked and there was an attitude of invincibility about the risks. Fewer nurses smoke now, but when NHS trusts first went smoke-free, it was an issue for some of the workforce. Long, tiring work shifts and a need for some ‘me time’ can make it hard for nurses who do smoke to quit, even though continuing with their habit flies in the face of common sense. Some nurses say they feel hypocritical giving patients face-to-face training on smoking cessation when they smoke themselves, but for nurses looking to quit this can be a valuable learning opportunity – stop-smoking services are there to help nurses too.

Conclusion

By delivering brief interventions and referring people to specialist stop-smoking services, nurses are ideally placed to help patients quit smoking and reduce the damage to health that smoking causes. Supporting people to choose good health over ill health is a great gift to impart and all nurses have a key part to play in this.

Key points

  • Smoking still causes more than 200 premature deaths in the UK every day
  • Half of primary and community care professionals do not offer recommended stop-smoking advice
  • Very brief advice from nurses on how to stop smoking can encourage more patients to quit if it is optimistic in tone
  • Combining treatment with specialist support has been shown to give people the best chance to stop smoking
  • Vaping, while not risk-free, is much safer than smoking and an effective way to stop smoking
References

Action on Smoking and Health (2019a) The End of Smoking: A Brief Guide for Local Authority Members and Officers and their Partners on Health and Wellbeing Boards.

Action on Smoking and Health (2019b) Fact sheet No. 12: Smoking and Mental Health.

Action on Smoking and Health (2018) Facts at a Glance: Key Smoking Statistics.

British Thoracic Society (2016) Smoking Cessation Policy and Practice in NHS Hospitals.

Department of Health (2017) Towards a Smokefree Generation: A Tobacco Control Plan for England.

Dockrell M (2018) Seizing the Opportunity: E-cigarettes and Stop Smoking Services – Linking the Most Popular with the Most Effective.

Hajek P et al (2019) A randomized trial of e-cigarettes versus nicotine-replacement therapy. New England Journal of Medicine; 380: 629-637.

Gemine RE et al (2018) Longitudinal study to assess impact of smoking at diagnosis and quitting on 1-year survival for people with non-small cell lung cancer. Lung Cancer; 129: 1-7.

Leonardi-Bee J et al (2011) Exposure to parental and sibling smoking and the risk

of smoking uptake in childhood and adolescence: a systematic review and meta-analysis Thorax; 66: 847, e855.

McNeill A et al (2019) Vaping in England: An Evidence Update February 2019 – A Report Commissioned by Public Health England.

McNeill A et al (2018) Evidence Review of E-cigarettes and Heated Tobacco Products 2018: A Report Commissioned by Public Health England.

National Institute for Health and Care Excellence (2018) Stop Smoking Interventions and Services.

National Institute for Health and Care Excellence (2013) Smoking: Acute, Maternity and Mental Health Services.

Peppone LJ et al (2011) The effect of cigarette smoking on cancer treatment-related side effects. The Oncologist; 16: 12, 1784-1792.

Press Association (2019) Vape Shops Open in Two UK Hospitals. guardian.com, 10 July.

Prochaska JO, DiClemente C (1982) Trans-theoretical therapy: toward a more integrative model of change. Psychotherapy Theory Research and Practice; 19: 3, 276-288.

Rosenberg G et al (2019) Smoking Cessation in Primary Care: A Cross-Sectional Survey of Primary Care Health Practitioners in the UK and the Use of Very Brief Advice.

Royal College of Physicians (2018) Hiding in Plain Sight: Treating Tobacco Dependency in the NHS.

Stead LF et al (2016) Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database of Systematic Reviews; 3: CD008286.

West R (2017) Tobacco smoking: health impact, prevalence, correlates and interventions. Psychology and Health; 32: 8, 1018-1036.

Zeng L et al (2019) Interventions for smoking cessation in people diagnosed with lung cancer. Cochrane Database of Systematic Reviews; 6: CD011751.

 

— Louise Ross to www.nursingtimes.net