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