elin roddy and david ross
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Elin Roddy and David RossBritish Thoracic Society Tobacco Committee
April 2007
Aims and ObjectivesTo ensure that all NHS staff directly involved
with patient care meet a basic set of core competencies to enable them to identify and support smokers who want to stop smoking
Pre-talk questions – true or false?1. Smoking is the commonest preventable
cause of death in the developed world2. COPD is the commonest cause of death in
smokers3. Smokers live on average 8 years less than
non-smokers4. Cutting down the number of cigarettes
smoked can be useful
Pre-talk questions – true or false?1. Most smokers smoke out of choice2. 25% of smokers want to quit smoking3. Nicotine withdrawal peaks at 3-5 days4. Using nicotine replacement therapy
doubles the chances of quitting5. Bupropion should only be used in hospital
patients
Where this fits – NICE guidanceBrief chats between people who smoke
and health professionals about stopping smoking are both effective and cost effective in helping people to stop smoking.
All health professionals should advise all smokers to stop smoking, not just those who are already ill.
Advice should be sensitive to individual needs.
NICE public health guidance: focus on smoking cessation and physical activity http://www.nice.org.uk/page.aspx?o=300139
Aims and ObjectivesKnowledgeSkills AttitudesAdditional competencies for prescribers
KnowledgeEffects of smoking on healthImplications of addiction to nicotineCessation strategies available to help
smokers to quitLocal smoking cessation services available
Effects of smoking on healthDeaths per year:120,000
Hospital admissions per year:365,000
GP consultations per year:1.2 million
Other cancer13%
Chronic obstructive pulmonary disease
20%
Other respiratory8%
Ischaemic heart disease20%
Other circulatory12%
Digestive2%
Lung cancer25%
Callum C. The UK Smoking Epidemic: Deaths in 1995. Health Education Authority 1998 p29Callum C. The UK Smoking Epidemic: Deaths in 1995. Health Education Authority 1998 p29
Deaths caused by smoking-related diseases
Men Women
Lifeexpectancy
Extra yearscompared to
smokers
Lifeexpectancy
Extra yearscompared to
smokers
Smoked until death
69.3 73.8
Never smoked 78.2 8.9 81.2 7.4
Quit at age 35 76.2 6.9 79.9 6.1
Quit at age 45 74.9 5.6 79.4 5.6
Quit at age 55 72.7 3.4 78.0 4.2
Quit at age 65 70.7 1.4 76.5 2.7
Taylor et al, AM J Public Health 2002;92:990-6
Benefits of Quitting Smoking
AddictionAddiction Disease and DeathDisease and Death
CarcinogensCarcinogensCarcinogensCarcinogens
Toxic gasesToxic gasesToxic gasesToxic gases
30% of all 30% of all cancerscancers
66% of all COPD66% of all COPD66% of all COPD66% of all COPD
13% of all 13% of all Vascular Vascular diseasedisease
13% of all 13% of all Vascular Vascular diseasedisease
CravingsCravingsCravingsCravings
SmokingSmokingSmokingSmoking
NicotineNicotineNicotineNicotine
A Vicious CircleA Vicious Circle
Peto R et al. Mortality from smoking in developed countries 1950 - 2000: Indirect estimates Peto R et al. Mortality from smoking in developed countries 1950 - 2000: Indirect estimates from National Vital Statistics. Oxford University Press 1994from National Vital Statistics. Oxford University Press 1994
NicotineNicotine
Carbon Carbon MonoxideMonoxide
TarTar AcetoneAcetone
CadmiumCadmium
ArsenicArsenic
Cigarette SmokeCigarette SmokeContains more than Contains more than 4,000 chemicals 4,000 chemicals including over 40 including over 40 known carcinogensknown carcinogens
No Smoking Day, UK. No Smoking Day Fact Sheet 4 1997No Smoking Day, UK. No Smoking Day Fact Sheet 4 1997
Hydrogen Hydrogen CyanideCyanide
Why are smoking cessation interventions important?Smoking remains common
28% adults smoke in the UKPrevalence essentially static over last 10 yearsIncreasing in young womenPrevalence up to 70% in deprived areas
Smokers would like to stop70% say that they would like to stop smoking
Few smokers can stop without helpEach year only 1% of smokers stop with willpower
aloneGeneral Household Survey 2000
0 5 10 15 20 25 30 35 40
Family/friend
Health professional
Advert
Poster
Restrictions
Health Problem
%%Base: 672 smokers currently trying to stop or made attempt to stop in past year.Base: 672 smokers currently trying to stop or made attempt to stop in past year.West R. Getting Serious About Stopping Smoking. A Report for No Smoking Day 1997West R. Getting Serious About Stopping Smoking. A Report for No Smoking Day 1997
Smoking Cessation strategiesWillpowerAlternative therapiesBrief advice from a health professionalBrief advice plus nicotine replacement therapy or
bupropionBehavioural support in small groups or
individuallyBehavioural support in small groups or
individually plus nicotine replacement therapy or bupropion
Effectiveness of smoking cessation*
0
5
10
15
Willpoweralone
Brief advice Brief adviceplus NRT
Intensivebehavioural
support
Intensivesupport +
NRT
Intensivesupport +
Zyban
% s
till a
bstin
ent a
t 6 m
onth
s
*No reliable data for success with alternative therapies
0 10 20 30 40 50 60
None/willpower
NRT
Health professional
Leaflet
Herbal Cigarette
Book
Alternative Therapy
Video
Clinic
Currently trying
Tried in past year
%%
West R. Getting serious about stopping smoking. A report for No Smoking Day 1997West R. Getting serious about stopping smoking. A report for No Smoking Day 1997
SkillsIdentifying all smokersDelivering brief opportunistic smoking
cessation advice to all smokersAssessment of patient’s commitment to quitReferring to local specialist smoking
cessation services
•ASK smoking status•ADVISE all smokers to quit•ASSESS willingness to quit
•ASSIST motivated smokers to quit•ARRANGE follow-up
What we should be doing – The 5 As
1. Ask smoking statusAll patients should be asked their smoking
status – ‘Current, Ex- or Never Smoker’This should be clearly documented in GP
notes, Medical notes, Nursing notes or AHP notes
Consider the use of a proforma or a stamp
2. Advise – Brief, Personalised
‘The best thing you can do for your health is to stop smoking, and I advise you to stop as soon as possible.’
‘You will start to feel the benefits of quitting smoking very quickly.’
‘There are things available free of charge or on prescription to help you give up.’
•‘Your asthma /angina/ circulation will certainly get worse if you carry on smoking.’
•‘Your inhalers will not work as well if you continue to smoke.’
•‘These breathing tests/X-rays already show some smoking related damage.’
3. ASSESS• Assess willingness to quit
– ‘How do you feel about your smoking?’– ‘Have you thought about giving up?’
If unwilling If willing
give information give or refer for assistance
4. ASSISTa) Help smokers to understand their smoking
behaviour
b) Give ‘common sense’ behavioural support
c) Prescribe nicotine replacement therapy or bupropion (this is covered later under ‘Additional Competencies for Prescribers’)
Understanding smoking behaviourHealth effects of nicotine/ smokeWithdrawal syndromeAddress misconceptions around
quitting:
‘Smoking helps me deal with stress’‘I’ll put on weight’‘I’ve switched to roll ups’‘My chest gets worse when I stop’
‘Common sense’ behavioural support•Set a QUIT DATE, tell friends and colleagues
•Identify and avoid smoking triggers
•Review past quit attempts
•Plan ahead for difficult times, relapses
5. ARRANGE follow up
• All patients should have access to a local specialist smoking cessation service
• Arrange follow-up with this service• Soon after quit date (ideally within 1
week)• Use exhaled carbon monoxide to
validate
AttitudesNon-judgemental approach to smokers Acknowledge role of addiction and
importance of support
- Most smokers do not choose to smoke but do so because they are addicted to nicotine
- Most smokers will not be able to give up without support
- Smokers have equal rights to best available treatments
SummaryHealth care professionals should understand that
most smokers smoke because of addiction to nicotine and not out of choice
Most smokers would like to quit , but the majority will not do so without help
All health care professionals should ask patients whether they smoke and offer brief, personalised advice to stop smoking to all smokers, not just those who are unwell
Health care professionals should know where to refer patients for extra support
Action PlanAsk your group – where and how do they see
themselves giving brief stop smoking advice?
And remember, in two minutes:An outpatient care assistant could advise a patient
with COPD about stopping smoking and where to find help
A junior doctor on a ward round could advise a patient with angina, and prescribe drug treatment
A physiotherapist doing a stair assessment with a stroke patient could give brief advice about stopping smoking and the ways to do it
A pre-op nurse could reduce post operative complications by delivering brief advice to a patient coming for hernia repair, and giving information on local stop smoking support available
Useful ReferencesNICE public health guidance: focus on smoking cessation
and physical activity http://www.nice.org.uk/page.aspx?o=300139
A guide to effective smoking cessation interventions for the health care system. Thorax 1998;53:suppl 5(1):S1-19.
‘Smoking Kills’ – A White Paper on Tobacco, 1998
Nicotine Addiction in Britain, RCP 2000
ABC of Smoking Cessation, BMJ 2004
Additional slides – specialty specific health effects and additional competencies for prescribers
Effects of smoking on healthEffects of smoking on health -CardiovascularSmokers are twice as likely as non-smokers to die
from ischaemic heart diseaseSmokers are six times more likely to die from an
aortic aneurysmPeople who have never smoked have a 30% greater
risk of ischaemic heart disease if they live with a smoker
Smokers are over three times as likely as non-smokers to have a stroke
A meta-analysis of smoking cessation after a heart attack shows that those who quit smoking are less likely to die*
*Wilson K Arch Intern Med 2000;160:934-944
Effects of smoking on health -Effects of smoking on health - Gastroenterology
Smoking is a risk factor for cancer of the pancreas and oesophagus
Reflux disease has a higher incidence and is more severe in people who smoke
Effects of smoking on healthEffects of smoking on health– Oncology: Small Cell Chemotherapy/Radiotherapy and Outcome
• Videtic et al, JCO April 2003• Retrospective study, 215 Pts.
Limited Stage• 42% continued to smoke• 58% non-smoking during CHT/RT• Median survival: 18 vs 13.6 months• 5-yr.: 8.9% vs 4%Videtic GMM, et al. JCO 21(8):1544-49, 2003.
Smoking Status during Radiation Therapy
237 patients, retrospective review of smoking hx, NSCLC
Current smokers had shorter survivalStage I/II: smokers had 2-yr survival 41%
with 13.7 months median survival compared to 56% with 27.9 months in non-smokers.
Fox, et al. Lung Cancer 2004
QOL and Survival in Lung CancerCurrent smoking is predictor of shortened
lung cancer survival*‘it may be mediated by biologic effects’Graces et al: Persistent smoking negatively
impacted QOL scores
*Tammemagi, CHEST January 2004
Effects of smoking on health -Effects of smoking on health - RheumatologySmokers are more likely to get rheumatoid
arthritis and it is more likely to be severeSmoking significantly increases the vascular
risk in patients with connective tissue diseases
Smoking exacerbates Raynaud’s disease
Effects of smoking on health - PaediatricsEffects of smoking on health - Paediatrics
Almost half of children in UK exposed to smoke at home
17,000 children admitted to hospital each year with effects of passive smoke
70% increase in respiratory tract infectionsIncrease in incidence and severity of asthmaIncrease in middle ear infectionsIncreased time off schoolChildren with parents who smoke are more
likely to become smokers themselves
Effects of smoking on health -Effects of smoking on health - PregnancyProblems conceiving 1.8 times more likelyDouble the risk of miscarriage or ectopic
pregnancyLower birthweight babiesTwo fold risk in pre-term labourIncreased risk of cot deathMay lead to inadequate breast milk
However - almost all of women who smoke before pregnancy do manage to stop once they become pregnant
Effects of smoking on health - Effects of smoking on health - PsychiatryStudies on people with mental illness living in the
community show high smoking rates - 70% in people with schizophrenia, 56% with depression (vs. 28% of population)
People with severe mental illness tend to smoke more cigarettes per day and have a high morbidity and mortality from cardiovascular and respiratory disease
However, mental health problems do not undermine the ability to stop smoking.
Stopping smoking does not appear to exacerbate psychotic symptoms and that experience of depression does not affect quit rates.
Patients with mental health problems need equality of access to smoking cessation support.
Effects of smoking on health - Effects of smoking on health - Respiratory89% of lung cancer deaths in men and
74% in women are attributable to smokingOver 80% of all COPD deaths are
attributable to smokingSmoking increases the risk of pneumoniaSmoking increases rate of exacerbations
and decline of FEV1 in asthmaticsContinued smoking reduces the
effectiveness of inhaled corticosteroids in asthma
Children who smoke are three times more likely to have time off school
Peto et al BMJ 2000
1.1. Fletcher CM, Peto R. The natural history of chronic airflow obstruction. BMJ 1977; 1(6077):Fletcher CM, Peto R. The natural history of chronic airflow obstruction. BMJ 1977; 1(6077):1645-16481645-1648
100100
7575
5050
2525
002525 5050 7575
Never smoked or notNever smoked or notsusceptible to smokesusceptible to smoke
Smoked regularlySmoked regularlyand susceptibleand susceptibleto its effectsto its effects
Stopped at 45Stopped at 45
Stopped at 65Stopped at 65
DisabilityDisability
DeathDeath
Age (in years)Age (in years)
FEVFEV11 (% of value at age 25) (% of value at age 25)
Effects of smoking on health - Effects of smoking on health - SurgerySmoking increases peri-operative mortality
and morbiditySmoking cessation is most effective if done at
least six weeks prior to surgerySmoking decreases wound healingRCT of smoking cessation prior to hip
surgery reduced complications from 52% to 18%*
*Moller AM et al, Lancet 2002,359;114-7
Breast Surgery and Smoking
Current smokers have increased risk of:Mastectomy flap necrosisHigher donor-site complications
Higher rate of abdominal flap necrosisHigher rate of abdominal hernia
Higher overall complication rate
Chang, Plast Reconstr Surg 2000,105:2374
Additional skills for prescribersKnowledge of indications for and side-effects
of nicotine replacement therapy and bupropion
Skills in prescribing the above treatments to support a quit attempt
Indications for NRTIndications for NRT
Use in all smokers who have had, or anticipate having, problems with nicotine cravings during a quit attempt
Adjunct, not alternative, to behavioural support
Reduces the symptoms of nicotine withdrawalProvides a coping mechanismMay make cigarettes less rewarding to smokeDoubles chance of successful quit attempt
Prescribing NRTAvailable on NHS prescription (which is cheaper
than buying over the counter)
Should be available on formulary in all hospitals
Use in those who smoke >10 cigarettes per day and have had, or anticipate having, problems with cravings
Patch - use 21mg/24h patch if morning cravings a problem, otherwise use 15mg/16h plus short-acting product for cravings
No form of NRT can mimic a cigarette
Cut Down Then Stop (CDTS)New indication for NRT6 studies to dateUsing NRT to reduce number of cigarettes
by 50% leads to long-term cessationNicorette gum and inhalator now licensed
for this indicationUseful for eg. smoke-free hospitals, where
patients may not want to quit but need to reduce number of cigarettes smoked
Speed of nicotine delivery
NRT - products availableHow to use Side effects
Patch Apply one 21mg or 16mg patch daily
Clean, unbroken skin
Use different site next day
Local skin rash
Insomnia (24 hour patch)
Gum Use as required
Chew until tastes strong
Rest between gum & cheek
Chew again when taste fades
Sore throat / mouth
Indigestion
Lozenge Use as required
Suck until tastes strong
Rest between gum & cheek
Suck again when taste fades
Sore throat / mouth
Indigestion
Inhalator Use as required
Insert 10mg cartridge in holder
Inhale as needed
Cartridge lasts 20-30 mins
Max 12/day
Sore throat / mouth
Indigestion
Nasal Spray Use as required
One 500mcg spray per nostril
Max. every 30 minutes
Maximum 64 sprays/day
Nasal irritation
Watery eyes
Cautions for NRTAlternative to NRT = Smoking
Care in acute cardiovascular events - short acting products
Safe in stable cardiovascular disease, peripheral vascular disease
No data yet in pregnancy – if cannot quit without, then use short acting preparation
Cautioned in patients on clozapine, olanzapine
But remember - most failed quitters do not use enough nicotine
Indications for bupropionSmokers who are motivated to quit and have
used NRT unsuccessfully, or who cannot use NRT
Generally used as a second line agentAs effective as NRT ie. doubles chances of
quitting successfullyVery safe despite adverse publicity (less likely
to cause fits than e.g. amitryptiline)
Dose regimen for bupropion
Roddy, E.L. in ‘The ABC of Smoking Cessation’. BMJ 2004
Side effects of bupropionInsomniaDry mouthFit (1:1,000 or lower)
Cautions for BupropionContraindicated in patients with current or past epilepsy
Contraindicated in patients with a history of anorexia nervosa and bulimia, severe hepatic necrosis, or bipolar disorder
Caution in patients with conditions predisposing to a low threshold for seizure:
– history of head trauma– alcohol misuse– on hypoglycaemic agents or insulin– drugs that lower the seizure threshold (for example,
theophylline, antipsychotics, antidepressants, and systemic corticosteroids).
SummaryMost smokers want to stop smoking but need
help to do soAll health professionals should ask and advise
about smokingUsing nicotine replacement therapy or
bupropion doubles the chances of a successful quit attempt
Assessment QuestionsQuestions have four stems each of which may
be true or false, apart from Question 4 where only one stem is correct
Answers can be found in the speakers notes accompanying each question
Question 1 – Health effects1. Non smokers live on average 8 years
longer than smokers2. COPD is the commonest cause of death
from smoking3. 1,000 UK hospital admissions per month
are due to smoking related problems4. Smokers stay longer in hospitals than
non-smokers
Question 2 - Addiction1. Most smokers find it easy to stop
smoking if they are motivated2. Nicotine can be as addictive as heroin or
cocaine3. Nicotine is the main substance in
cigarettes that causes harm4. Withdrawal from nicotine peaks at 3 – 5
days after quitting but can last for many weeks
Question 3 – Cessation strategies1. Half of smokers would like to stop
smoking2. Willpower alone is the most effective
way to stop smoking3. Around a quarter of those smokers
trying to quit do so because of advice from a health professional
4. Switching to roll-ups is less harmful than smoking cigarettes
Question 4 – The 5 A’sWhat are the 5 A’s of smoking
cessation? Only one answer is correct!
1. Ask, accept, assess, alter, arrange2. Ask, advise, assess, assist, arrange3. Ask, accept, advise, assess, assist4. Ask, advise, alter, assist, advance
Question 5 - Quitting1. Cutting down can be useful before quitting2. Because smoking relieves stress, smokers
are less stressed than non-smokers3. Using nicotine replacement therapy doubles
your chances of quitting successfully4. Using nicotine replacement or bupropion
reduces the amount of weight gain when quitting
Question 6 - Attitudes1. Most smokers smoke out of choice2. Smokers have less willpower than non-
smokers3. People who smoke are not eligible for
certain treatments from the NHS4. Most smokers will not be able to give up
successfully without support
Question 7 – Nicotine Replacement1. Nicotine replacement therapy doubles the
chance of quitting smoking successfully2. Nicotine patches are more effective than
gum or lozenges3. Nicotine patches are expensive4. The nicotine nasal spray is the fastest
acting nicotine replacement and is good for people who are heavily addicted to nicotine
Question 8 – Bupropion1. Bupropion is generally safe if used
correctly2. Bupropion is more effective than
nicotine replacement therapy3. Bupropion should not be used in
smokers with COPD4. Bupropion can be used with nicotine
replacement therapy under supervision