Publication
Encouraging smokers to stop: what you can do
How to use this guide
This guide is for all health professionals who see smokers during the course of their work. Raising the issue of smoking and giving the brief advice outlined in this guide will only take a few minutes of your time.
This guide is for you to use during your routine consultations with smokers. To keep it as clear as possible‚ qualifying phrases like — if possible‚ if you have time‚ when appropriate — should be taken as read; we have kept them to an absolute minimum. The guide has been designed so that you can scan it quickly and easily find the section you need.
Why your role is so important explains why it is so worthwhile for you to raise the issue.
Flow chart takes you through the basic steps involved in advising smokers. If necessary you can use it by itself. The What you can do: a step-by-step guide section is based on the structure of the flowchart. briefly describes the products that should be used as part of a smoker’s quit attempt.
Smoking cessation services and further help gives information on services and further support‚ and The health risks summarises information you can give briefly to smokers unaware of the dangers of smoking.
The lung function diagram on the inside back cover can be used to show smokers Why it is worth stopping.
The wording of the suggested questions to smokers are for guidance only. Use words you feel comfortable with.
This guide is based on systematic reviews of the evidence‚ outlined in the Smoking Cessation Guidelines for Scotland: 2004 Update‚ published by Health Scotland and ASH Scotland and available at www.healthscotland.com/tobacco. Any treatments not mentioned in this guide either have insufficient evidence of effectiveness‚ or are not regarded as first-line treatments.
Flow chart
This flow chart summarises the section What you can do: a step-by-step guide.
We have mostly framed specific questions but we recognise that you will want to convey the meaning in your own words.
Why your role is so important
By raising the issue of smoking and referring smokers who want to stop to the local treatment services‚ you will be offering them the best chance of succeeding in stopping. They can now get help from a network of evidence-based smoking cessation services across Scotland‚ where specialist staff offer intensive‚ expert support.
Your intervention is extremely worthwhile.
This is because‚ firstly‚ smoking cessation is effective in preserving life.
The Smoking Cessation Guidelines for Scotland: 2004 Update ‚ based on systematic reviews of the evidence‚ show that the more support smokers are given in stopping‚ the higher the success rates (see diagram). Brief opportunistic advice‚ normally taking less than three minutes‚ results in about 2% stopping long term‚ over and above those who would have stopped anyway without help. Although this might sound rather low‚ it is very cost effective. However‚ the main effect of brief advice is to trigger a quit attempt and so its real value will be if it can persuade smokers to seek support from the smoking cessation services.
Face-to-face behavioural support helps about 8% of smokers stop long term (over and above those who would have stopped anyway). These cessation rates are approximately doubled by adding support from nicotine replacement therapy (NRT) or bupropion (Zyban®).
Treatment is also very cost effective. Most smoking cessation treatments cost less than £1‚000 per life year gained. The median cost per life year gained of 300 life-saving medical interventions has been estimated in one review as £17‚000(2)
Approximate percentage of quit attempts achieving at least six months of continuous abstinence as a function of treatment(1)
In 2002 the Health Technology Board for Scotland (HTBS) (now part of Quality Improvement Scotland) advised that the guidance on NRT and Zyban® from the National Institute for Clinical Excellence (NICE) in England was valid for Scotland(3). It concluded that NRT and Zyban® are among the most cost effective of all healthcare interventions and should be recommended to smokers who want to stop . Smoking cessation thus provides outstanding value for money (2).
This means that even low cessation rates produce health gains far more cheaply than most medical interventions. Helping smokers stop is therefore an excellent investment which will‚ in the medium to longer term‚ save money and release it for other interventions.
The figures above show that a worthwhile intervention need only take a few minutes of your time.
What you can do: a step-by-step guide
* see section titled "SMOKING CESSATION SERVICES AND FURTHER HELP"
Medications
Both NRT and Zyban ® are effective treatments‚ even with limited support‚ so although the treatment of choice is behavioural support plus medication‚ medication with limited support can also be beneficial and may be more acceptable to many smokers (1).
We only have space in this guide to give brief details of the medications. If you have any doubts or questions about medications that are not covered here‚ we recommend that you consult the full guidelines‚ and/or to contact your local smoking cessation service.
Which product?
One study that compared a nicotine patch with Zyban ® found the latter to be more effective‚ however one study is insufficient evidence to recommend Zyban ® over NRT. The overall effect size for Zyban ® is very similar to that for NRT in comparable studies‚ thus both are considered first-line treatments(1).
If a smoker arrives with a clear preference for one form of medication‚ it can be offered unless it is contraindicated. Otherwise check for contraindications to all the products and offer a choice between the products that are permitted. It should be noted that advice on NRT and pregnant smokers has recently been changed in the British National Formulary Number 46 to reflect the NICE guidance and pregnancy is no longer listed as a contraindication for NRT.
NRT
There are six NRT products and all have similar effectiveness‚ except that the 4mg gum is more effective than 2mg gum in more dependent smokers.
Thus the choice between them is a practical one:
Patch — it is discreet and easiest to use
Gum — it allows good control of nicotine dose
Spray — better for very addicted smokers
Inhalator — good if smoker misses the ritual of smoking
Tablet — discreet and flexible‚ good dose control
Lozenge — discreet and flexible‚ good dose control
There is no scientific basis for disallowing different forms of NRT to be combined and there may be some benefit to combinations. The most common combinations are of an acute dosing form‚ such as the nasal spray or the inhalator‚ with the patch. It is recommended to prescribe NRT for only two weeks in the first instance‚ with a second or subsequent prescription(s) offered only if the smoker demonstrates a continuing quit attempt.
Zyban ®
Zyban ® is the trade name for bupropion hydrochloride sustained-release (SR)‚ which comes as a tablet. It is an anti-depressant although its effect on smoking appears to be unconnected with this. It does not contain nicotine but the way it helps smokers stop is not known. However‚ it is effective and‚ like NRT‚ has been shown in scientific trials to double a smoker’s chance of stopping. There is not enough evidence yet to know if it may be more effective than NRT.
No recommendation can currently be made on when Zyban ® should be preferred over NRT or vice versa‚ other than those for which one of the drugs is contraindicated. It is recommended to prescribe Zyban ® for four weeks and then four weeks. This avoids a potentially large waste of medication and money in quit attempts that do not last beyond a week or two.
Concerns about safety
oncerns have been expressed in the media over the safety of Zyban ® . It has a similar safety profile to modern anti-depressant drugs that are generally considered safe (4). The Summary of Product Characteristics for Zyban ® declares a seizure risk of 1 in 1000 but this can be mitigated by ensuring that patients are carefully screened for pre-disposing factors. Common side-effects are insomnia and dry mouth but these are rarely serious enough for patients to discontinue treatment.
Smoking cessation services and further help
Smoking cessation services
There is now a well-established infrastructure of specialist smoking cessation services in every NHS Board in Scotland. Smoking cessation services provide intensive support either in groups or through individual counselling that will:
- help smokers to structure their quit attempt
- make sure that smokers are adequately prepared
- use social support (in groups) to maintain and increase motivation to succeed
- provide smokers with information about how to avoid or cope with urges to smoke
- provide smokers with reassurance and advice on withdrawal symptoms
- provide guidance on the correct use of medications.
However‚ the organisation of services varies from area to area according to local population‚ geography and demand. Smoking cessation co-ordinators should ensure that health professionals in their area
have up-to-date information on local services. If you require further information about services please contact your NHS Board smoking cessation co-ordinator.
Information about local services is also available from Smokeline:
t 0800 84 84 84 or the Health Scotland website:
www.healthscotland.com/tobacco. Look in the Smokefacts section and click on ‘database of local services’.
Another specialist tobacco site‚ Tobacco Unwrapped‚ contains useful information and materials on a range of other tobacco control issues: www.healthscotland.com/tobacco
Smokeline
Any smoker can ring the free telephone helpline t 0800 84 84 84 (noon until midnight) for confidential support and advice.
Smokers can get advice via email from www.healthscotland.com/tobacco
Other treatments
A wide range of treatments have been tested as aids to smoking cessation‚ and some of them‚ for example hypnosis and acupuncture‚ have a high profile and tend to be sought after by smokers. Many are promoted commercially‚ most with unproven claims for effectiveness‚ some with little evidence of effectiveness over and above a placebo effect (although a placebo effect can be valuable). Health professionals should give smokers enough information about other treatments to enable them to make an informed choice‚ but without discouraging attempts to stop. Unproven treatments‚ including hypnosis‚ acupuncture and laser therapy‚ should not be actively promoted by or provided by the NHS. As with NRT and Zyban ® ‚ if smokers want more information on other treatments than you are able to provide‚ refer them to the treatment services.
Other websites
Ash Scotland: www.ashscotland.org.uk/quit/index.html
NHS Health Scotland: www.healthscotland.com
www.treatobacco.net is run by the World Health Organization and Society for Research on Nicotine and Tobacco‚ and contains independent‚ authoritative reviews of the effectiveness and safety of treatment for dependent smokers in 10 languages: Arabic‚ Chinese‚ English‚ French‚ German‚ Italian‚ Japanese‚ Portuguese‚ Russian‚ Spanish.
The health risks
When you ask smokers Are you aware of the damage smoking can do to your health? most will know the answer expected of them‚ but probably don’t know how great the risk is.
However‚ you are not going to persuade them of the risks in a few minutes‚ especially if they are sceptical.
So your goal is not to persuade them that smoking is dangerous‚ but to offer information‚ in case they are receptive.
Keep this discussion short and base it on a leaflet that they can keep. Use the information below selectively and appropriately — for the setting‚ and the smoker. It is for all smokers: adapt it as necessary‚ especially for young people‚ who may be less worried about long-term health risks and more worried about short-term effects‚ like bad breath or discoloured teeth.
The two key messages to offer are that smoking is dangerous but that it is worth stopping . The risk of getting serious disease‚ like cancer or heart disease‚ starts falling as soon as smokers stop.
Both are important. Many smokers know smoking is bad for them but don’t try to stop because they believe they will fail. One of the most important things you can do for them in this consultation is to tell them that they can get effective help to stop.
Some facts that may have impact
Smoking causes lung cancer‚ chronic bronchitis and emphysema‚ and coronary heart disease. About 80% to 90% of lung cancers and bronchitis and emphysema are caused by smoking‚ and about 20% to 25% of heart disease.
The average smoker will lose about 10 years of life because of their smoking (5). For some this will be the difference between seeing their grandchildren growing up or not.
Approximately 13‚000 people die from their smoking each year in Scotland — that’s 250 every week.
At a more local level‚ in a street with 150 adults‚ of which about 45 smoke‚ about 20 will be killed by their smoking.
An excellent source on the health risks is the Royal College of Physicians report Nicotine Addiction in Britain (6).
Smoking and oral health
Smoking is associated with calculus‚ halitosis‚ leukoedema‚ premature tooth loss‚ staining and abrasion‚ periodontal disease‚ acute necrotising ulcerative gingivitis‚ and several potentially malignant oral lesions.
Smoking and pregnancy
Cigarette smoking is the largest single modifiable risk factor for pregnancy-related morbidity and mortality (7) and is a major cause of health inequalities.
Women who smoke during pregnancy:
- have a 27% higher chance of a miscarriage
- increase by 33% the risk of perinatal mortality
- are twice as likely to experience premature labour
- are three times more likely to have a low birthweight baby (on average 200gms or around 7oz lighter on average)
- are more likely to have children who suffer breathlessness and wheezing in the first six months of their life.
It is now accepted that stopping at any stage during pregnancy is beneficial.
Second-hand smoke
Exposure to second-hand smoke (sometimes called passive smoking) is associated with:
- acute respiratory illness in early childhood
- chronic cough‚ phlegm‚ and wheeze in children
- chronic middle ear effusions in children
- reduced levels and growth of lung function in children
- increased risk of sudden infant death syndrome (SIDS)
- increased bronchial hyper-responsiveness in asthmatics
- increased lung symptoms in asthmatics
- decreased lung function in asthmatics
- irritation to the eyes‚ nose‚ throat
- increased risk of lung cancer and heart disease with long-term exposure.
Also‚ there is now evidence that even short-term exposure to second-hand smoke causes an acute physiological response that can induce heart attacks in some people (8).
References
(1) West R‚ McNeill A‚ Raw M (2004). Smoking Cessation Guidelines for Scotland: 2004 Update . Edinburgh: NHS Health Scotland and ASH Scotland. www.healthscotland.com/tobacco
(2) Raw M‚ McNeill A‚ Watt J (2001). The Case for Commissioning Smoking Cessation Services . London: WHO Europe Partnership Project & SmokeFree London. www.ash.org.uk/html/cessation/servicescase.pdf
(3) Health Technology Board for Scotland (2002). Nicotine Replacement Therapy (NRT) and Bupropion (Zyban ® ) to Help Quit Smoking: Understanding HTBS Advice . Glasgow: HTBS. http://docs.scottishmedicines.org/docs/pdf/HTBS%20ADVICESMOKING%20A5.pdf
(4) National Institute for Clinical Excellence (2002). Technology Appraisal Guidance No. 39. Guidance on the Use of Nicotine Replacement Therapy (NRT) and Bupropion for Smoking Cessation . London: NICE. www.nice.org.uk/pdf/NiceNRT39GUIDANCE.pdf
(5) Doll R‚ Peto R‚ Boreham J‚ Sutherland I (2004). Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ ; 328:1519-28.
(6) Royal College of Physicians Tobacco Advisory Group (2000). Nicotine Addiction in Britain . London: Royal College of Physicians. www.rcplondon.ac.uk/pubs/books/nicotine/index.htm
(7) West R (2002). Smoking cessation and pregnancy . Fetal and Maternal Medicine Review ; 13:181-194.
(8) Pechacek TF‚ Babb S (2004). How acute and reversible are the cardiovascular risks of second-hand smoke? BMJ ; 328:980-983.
(9) Raw M (1994). Why It Is Worth Stopping . London: Health Education Authority.
Why it is worth stopping
Stopping smoking has immediate benefits for men and women of all ages‚ irrespective of whether they already have a smoking-related disease.
- In 20 minutes blood pressure and pulse rate return to normal.
- In 20 hours carbon monoxide will be eliminated from the body.
- In 3 days breathing becomes easier — the bronchial tubes begin to relax.
- In 3 months circulation improves.
- In 3 to 9 months lung function improves by about 10%.
- In 1 year the risk of a heart attack falls to about half that of a smoker.
- Long-term stopping smoking reduces the risk of lung cancer‚ heart disease‚ strokes‚ chronic lung disease and other cancers.
- The risk of serious disease starts going down immediately.
- This diagramshows the benefit to your lungs if you stop smoking (9).
- Although the measure in the diagram is FEV1 ‚ it’s real value is to illustrate to the smoker visually the benefit of stopping.
- Lung function gets worse as you get older‚ but normally only very slowly and very slightly ( Non-smoker line).
- In smokers lung function can get worse much more quickly. For example‚ the diagram shows a smoker who becomes disabled with emphysema at 56 ( Smoker line).
- If you stop smoking you delay the damage to your health‚ and if you stop soon enough there will be no damage ( Stopped at 45 line).
These data are from: Fletcher D‚ Peto R (1977). The natural history of chronic airflow obstruction. BMJ 1:1645-48. The text under the diagram is approved by Professor Richard Peto.