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Smoking Cessation
GP, Leeds, UK
GP, Pershore, UK
Executive Editor, InnoVAiT
Email: chantal.simon{at}oxfordjournals.org
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Abstract |
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 TOP Abstract IntroductionHealth risks of smokingSmoking and the quality...Helping people to stop...References |
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In the UK, 25% of adults smoke cigarettes, 1% smoke a pipe regularly and 4% of men smoke at least one cigar per month. Of the cigarette smokers, 34% hand-roll their cigarettes, 55% would find it hard to go a whole day without a cigarette and 17% (mostly heavy smokers) have their first cigarette within 5 min of waking up. Overall, a slightly higher percentage of men (26%) than women (23%) smoke. Prevalence is highest in those aged 20–34 and then declines with age (Fig. 1).
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Introduction |
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TOPAbstractIntroductionHealth risks of smokingSmoking and the quality...Helping people to stop...References |
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More than 80% of adult smokers started smoking in childhood. Among school children, the proportion of regular smokers increases with age and girls are more likely to smoke than boys. Only 1% of children are smokers when they enter secondary school, but by the age of 15 years, 26% of girls and 16% of boys smoke at least one cigarette per week (Fig. 2). The mean number of cigarettes smoked by this age group is six to seven cigarettes per day.
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Smoking prevalence fell substantially in the 1970s and early 1980s in all age groups, but particularly among those aged over 25 years. As well as prevalence, the number of cigarettes consumed by smokers also declined in the same time period. However, since then the rate of decline has slowed. Government targets aim to reduce smoking to 24% of adults and 9% of children by 2010.
Surveys of smokers show that 73% want to stop and 30% intend to give up within a year. Nine in ten give a health-related reason for wanting to stop smoking, and the effects of passive smoking on children are a common reason cited by smokers with children in the household. This article aims to provide the GP in training with a strategy to assist smokers seen in primary care to stop smoking.
| The GP curriculum and smoking cessation General practitioners (GPs) have a crucial role to play in promoting health and preventing disease. During the consultation, there are excellent opportunities to discuss healthy living with the patients. More important than the GP's role is that of the patient through self-care. To put patients at the centre of their care, GPs need to possess appropriate skills to support people, taking them through a range of approaches, in partnership, recognizing that the individual should make the choices, decisions and take the actions themselves. Smoking cessation assessment, advice and management is a key component for prevention of both cardiovascular and respiratory disease within the GP curriculum (topics 15.1 and 15.8, respectively). In particular, a GP should be able to:
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Health risks of smoking |
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TOPAbstractIntroductionHealth risks of smokingSmoking and the quality...Helping people to stop...References |
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Smoking is the greatest single cause of illness and premature death in the UK. Half of all regular smokers will eventually die as a result of smoking, accounting for 106 000 deaths per year in the UK, or one in six of all deaths.
Tobacco smoking is associated with increased risk of:
- Cancers: About 30% of all cancer deaths are smoking related. More than 85% of lung cancers occur in smokers. Other cancers with increased incidence in smokers include lip and mouth cancers, stomach cancer, colon cancer and bladder cancer.
- Cardiovascular disease: Smoking increases the risk of arteriosclerosis. Smokers are at increased risk of coronary heart disease, stroke and peripheral vascular disease. The co-existence of other risk factors for cardiovascular disease in a smoker, such as diabetes mellitus or hypercholesterolaemia, increases risk still further. Smokers are also at increased risk of venous thrombosis, especially if they are taking the combined contraceptive pill.
- Chronic lung disease: Smoking is the major cause of chronic obstructive pulmonary disease (COPD) and smoking cessation is one of only two treatments proven to decrease progression of and mortality from COPD. Smokers are also more prone to recurrent chest infections and exacerbations of asthma.
- Gastrointestinal disease: Smoking is strongly protective against ulcerative colitis (95% are non-smokers or ex-smokers) but a causative factor in Crohn's disease (two-thirds are smokers and smoking cessation halves the relapse rate). Smoking is also a risk factor for dyspepsia and gastric ulcers.
- Pregnancy: Smokers are more likely to have infertility problems than non-smokers. Smoking reduces ovulation, reduces a man's sperm count and motility. Once a woman is pregnant, smoking doubles the miscarriage rate and also increases the risk of ectopic pregnancy. Smokers have an increased risk of placenta praevia, placental abruption, premature rupture of membranes and pre-term delivery. Babies born of mothers who are smokers are on average 200 g lighter than those born to non-smokers and have an increased risk of cleft deformities and increased perinatal mortality.
- Other conditions: Smokers are more at risk of diabetes mellitus and osteoporosis. Stopping smoking prior to the menopause reduces the risk of osteoporosis by 25% after the menopause.
Passive smoking
Passive smoking is also associated with health risks. People regularly in contact with other people's cigarette smoke have an increased risk of both coronary heart disease and lung cancer (risk of lung cancer is increased by 25%). Children living in smoker's homes have an increased risk of bronchitis, otitis media and cot death.
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Smoking and the quality and outcomes framework |
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TOPAbstractIntroductionHealth risks of smokingSmoking and the quality...Helping people to stop...References |
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Due to the health impact of smoking, it features heavily in the quality and outcomes framework (Table 1). Practices are rewarded for recording smoking status in all patients over the age of 15 years and providing information, advice and treatment to smokers. In addition, under the smoking domain, practices are rewarded for recording the smoking status of their patients with diseases linked to smoking (coronary heart disease, stroke or transient ischaemic attack, hypertension, diabetes, COPD or asthma) and offering them advice about smoking cessation or referral to a stop smoking service. Under the asthma domain, practices are further rewarded for recording smoking status of adolescents aged 14–19 years with asthma.
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Helping people to stop smoking |
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TOPAbstractIntroductionHealth risks of smokingSmoking and the quality...Helping people to stop...References |
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Smoking cessation information can start before you ever see a patient. Posters and leaflets in the surgery and information in the practice leaflet advising patients about the risk of smoking and ways to give up may prompt even those patients who see the doctor rarely to think about stopping.
In the surgery or clinic, ask patients who have ever smoked if they are smokers at least once a year. Advice from a GP about smoking cessation results in 2% of smokers stopping and 5% if the advice is repeated. If the patient has a health problem caused or worsened by smoking, link your advice to that problem. Strong motivation is vital to successfully stop smoking. An episode of poor health directly related to smoking, such as a myocardial infarct, is a powerful motivator.
If a patient is a smoker, provide advice about the risk of smoking and advise the patient to stop (Fig. 3). Assess whether the patient wants to stop and whether he or she is ready to make the commitment to stop at that point in time. A useful framework for management of smoking cessation is the stages of change model (Table 2).
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If the smoker does not want to stop, then record that you have given advice about smoking cessation and give the patient information to take home about smoking risks and ways to stop smoking. Ask again whenever you see the patient in the future.
If the smoker does want to stop smoking, explore why that decision has been made and reinforce those reasons. Discuss how the patient wants to stop. It may be easier if all family members who smoke try to give up together.
Advise the patient to set a stop date and stick to it, avoiding cigarettes completely after that date. Additional strategies that may be helpful include:
- Avoidance of situations in which smokers would normally smoke can be useful, for example ensuring that there are no cigarettes in the house or going straight home rather than stopping after work for a drink and a cigarette.
- Diversion tactics to use when tempted can also be helpful, such as sucking sweets or chewing gum.
- Methods of increasing motivation, apart from linking smoking to current health problems, include working out the money that the smoker could save by not smoking (a calculator is available on website: www.givingupsmoking.co.uk) or suggesting that the smoker is sponsored to stop smoking by friends and family with proceeds going to charity.
| Box 1. Useful contacts for smokers Action on smoking and health (ASH)—Tel: 020 7739 5902, website: www.ash.org.uk. NHS Smoking Helpline—Tel: 0800 169 0 169 (0800 169 9 169 for pregnant women), website: www.gosmokefree.co.uk. Quit Helpline—Tel: 0800 00 22 00, website: www.quit.org.uk.
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Formal support
In many areas ‘stop smoking’ services are provided by Primary Care Trusts. These programmes vary from area to area but generally consist of a combination of group education, counselling and support and/or individual support in combination with drug therapy. Around 530 000 people set a quit date through NHS stop smoking services in England in 2004/05. When followed up 4 weeks later, 56% were still not smoking. Success rates increased with age, from 39% of those aged under 18 to 66% of those aged 60 and over. Despite the widespread use of this type of support, there is very little evidence that it increases smoking cessation rates over and above rates achieved using medication alone.
Medication
Three different medications are available on prescription to aid smoking cessation in the UK. Prescribe smoking cessation medication only for smokers who commit to a target stop date. Initially prescribe only enough to last 2 weeks after the target stop date (2 weeks’ nicotine replacement therapy or 3–4 weeks’ bupropion or varenicline). Only offer a second prescription if the smoker demonstrates continuing commitment to stop smoking. If the smoker is unsuccessful in stopping smoking, the NHS will not fund another attempt for the next 6 months.
Nicotine replacement therapy (NRT) is available both over the counter and on prescription in many different guises—inhalators, patches, sublingual tablets, lozenges and gum. All preparations are equally effective and increase the chance of stopping smoking by one-and-a-half times. NRT is currently the only preparation licensed for use to aid smoking cessation for smokers aged 12–18 years. It can also be used to aid smoking cessation for pregnant women, although should be reserved for use only if smoking cessation without nicotine replacement fails. For pregnant women, intermittent therapy is preferable and licorice-flavoured products should be avoided. NRT is contraindicated for patients who have recently suffered a myocardial infarct, stroke or transient ischaemic attack, and for patients with arrythmias. Start with higher doses for smokers who are highly dependent and continue treatment for 3 months, tailing off the dose gradually over 2 weeks after that time before stopping (except gum which can be stopped abruptly).
Bupropion (or Zyban®) is available only on prescription and licensed for smoking cessation in adults. It is an effective treatment that doubles smoking cessation rates. It is contraindicated for smokers who are pregnant or breastfeeding, or those with epilepsy or increased risk of seizures, eating disorders or bipolar disorder. Smokers should start taking the tablets 1–2 weeks prior to the day that they intend to stop smoking (150 mg daily for 3 days, then 150 mg twice daily for 7–9 weeks). There is currently no evidence that combination of bupropion with NRT increases cessation rates over and above each agent alone.
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Varenicline (Champix®) is also available only on prescription. It is licensed for adults who wish to stop smoking and, like bupropion, doubles cessation rates. It is contraindicated in pregnancy and should be used with caution if the patient has a past history of psychiatric illness. Advise smokers to start taking the tablets a week before their intended stop date (0.5 mg daily for 3 days, 0.5 mg twice daily for 4 days and then 1 mg twice daily for 11 weeks). Tablets should be taken after food and with a full glass of water. Decrease the dose to 1 mg daily if the smoker has renal impairment or is frail or elderly. If the smoker is successful in stopping smoking after 12 weeks, consider prescribing a further 12 weeks of treatment to decrease the chance of relapse.
Alternative therapies
Although widely used, there is very little evidence that alternative therapies are effective for helping with smoking cessation. In particular, there is no evidence that acupuncture is effective but there is some evidence that hypnotherapy may be helpful.
Key points
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References |
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TOPAbstractIntroductionHealth risks of smokingSmoking and the quality...Helping people to stop...References |
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Brunnhuber K, Cummings KM, Felt S, Sherman S, Woodcock J. Putting evidence into practice: smoking cessation. In: Clinical Evidence (2007) BMJ Publishing.
NICE Guidance. Brief Interventions and Referral for Smoking Cessation in Primary Care and Other Settings (2006) Available from: www.nice.org.uk/nicemedia/pdf/PH001_smoking_cessation.pdf [date last accessed 11.12.2007].
NICE Guidance. Smoking Cessation—Bupropion and Nicotine Replacement Therapy (2002) Available from: www.nice.org.uk/guidance/index.jsp?action=byID&;r=true&o=11452 [date last accessed 11.12.2007].
NICE Guidance. Smoking Cessation—Varenicline (2007) Available from: www.nice.org.uk/guidance/index.jsp?action=byID&;r=true&o=11809 [date last accessed 11.12.2007].
Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology (1983) 51:390–395.[CrossRef][Web of Science][Medline]
Simon C, Everitt H, Kendrick T. Oxford Handbook of General Practice (2005) Oxford University Press: Oxford.
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