Smoke-Free Challenges & ‘Butts’: strategies

to engage patients, carers & staff

Dr Peter Mackereth (Former) Tobacco Control Lead

Charlotte Finchett Lead Health Advisor

The Christie NHS Foundation Trust

Manchester

Agenda:

To examine how we can

engage patients, carers

and staff in smoking

cessation services,

exploring the ‘butts' and

benefits of going smoke

free based on case

studies, interventions and

strategies to help

individuals make the

change

Smoking, Cancer & Treatment

Contains 4,000 chemicals including:- arsenic,

formaldehyde, butane, acetone, methanol

NOW 30% sugar!! – increased sweetness & burn attracts

young people & women

Carbon monoxide (poisonous invisible gas) – prevents

oxygen transport & detrimental effects on healing (XRT &

surgery)

Contraindicated with chemotherapy – effects on uptake &

circulation

Increases risk of nausea & vomiting with chemotherapy

Higher rates of recurrence & new lung primaries

Smoking & Drug Interactions e.g.

Heparin – increased clearance & decreased half life

Beta- blockers - less effective antihypertensive & rate control effects

Insulin – decreased insulin absorption, antagonizes the effects of insulin, higher insulin dose needed

Opioids - smoking decreases analgesic effects so higher doses needed

Chemotherapy – higher doses required – more mutations so harder to treat

Antidepressants & anxiolytics – higher dosages required in people who smoke

Smoking as a dirty deadly delivery system

Sexing up the use of NRT

E-cigarettes – 3 million users switching – some evidence of dual use & dialling down nicotine level

Don’t forget - snuff, shisha, paan/ betel leaf & cannabis

Smoke Free Site – no shelters

Compliance with NICE guidance

CQC inspection highlighted work of the Christie Health advisors

Ecological impact of smoking – detritus & release of toxins from butts

Teachable moment! – But I am

telling you… I want to carry on smoking. It’s the only

thing that gives me pleasure… I’ve nothing

to look forward to now I have cancer

Don’t ask me to stop right now… I am here

for investigations… not going to get

through today without a cig

I have COPD and lung cancer and I’m in

and out of hospital …smoking makes my

life bearable

I’m here with my mum every day… it gets

me out of the ward and breaks the

boredom of hanging about

Staff …

Student nurse seen by

manager setting with a

patient in a wheelchair

smoking.

Student later explained that

she is sent out at least three

times a day with the patient –

she does not smoke. This

she says this happens to

students at other hospitals

too

Patient seen speaking very

loudly to a nurse smoking in

uniform outside the hospital

….I am shocked… I have

cancer and I was told to stop

and here you are smoking… I

am disgusted

Health Advisor bleeped by

OPD manager to talk to the

nurse

Challenges & ‘Buts’ from Staff

Ignoring the issue - collude with the tobacco industry – but ‘it’s a choice’...it’s lifestyle

But not my role

HCPs that smoke

Being seen as judgmental

Need to value BIT & SEEDING change

Going Smoke free – can be a bumpy journey

Arguments for hospital based Health Advisors

Nurses & Smoking

1- 52 % across the world

Highest – Serbia male

(52%) female (47%)

Lowest – China female

(2%)

45% of nurses who

smoke wanted to stop

11% of Australian nurses

smoke (acute care)

8% of workforce @ the

Christie smoke

Reasons/triggers

/issues

Addiction

Work pressures/ time out

Cope with anxiety

Weight gain concerns

Family/friends smoke

Relationships –

separated/divorce/

loneliness

Shame/ awareness of the

smell

CQUINS Pre-Op, Lung & H&N (4,000)

plus staff training (1,000)

Targeted H&N, lung, breast cancer,

pre-operative Clinics & Wards

Head & Neck Project – reducing

mucositis, insertion of PEGs & hospital

admissions (Stringer et al, 2015).

Survivorship – Podcasts & Health

Events

Smoke Free Site & Services Staff

Survey (Mackereth et al, 2015)

LGBT ‘Proud2BSmokefree’ work

Smoking & Vaping (Heyworth et al,

2017)

The Christie Smoking Cessation Activities

Smoke Free Sites NICE recommendations –

opportunistic rapid access to SC support (NRT) for patients, carers & staff

Singing from same hymn sheet - heard it from doctors, nurses …and pharmacists

‘Walk of shame’ – drip stand by the side of the road.

Risks – increase anxiety & phobias, fire, falls, poor wound healing, delays in discharge etc etc

The Christie NRT Products & Services

Patches □7mg/24 hrs □ 14 mg/24hrs

□ 21mg/24hrs

Lozenge □ 1mg □ 2mg

Inhalator □ 15mg cartridges

Team: Clinical Lead/FT Health Advisor plus 3

PT Advisor/therapists

Interventions: NRT advise/support,

hypnotherapy, stress management techniques

& complementary therapies .

Reframing NRT…sexing it up?

Use NRT to “manage” smoking

Change your brand … provide a choice

Using NRT products innovatively

as…fun… special… black inhalator to

match dress

Getting celebs on board to promote NRT

as life style choice …got my

condoms…got my NRT …on my way

Vaping/e-cigs They are designed to look & feel like normal cigarettes.

Heating element inside that vapourises a solution - this looks like smoke. Glycol plus traces of lead, tin cadmium, flavourings – maybe carcinogenic/irritant

May contain nicotine in varying doses.

Growing in popularity 3 million+ in UK

Recent research paper from The Lancet showed that the e-cigarettes were as effective as nicotine patches.

Further studies are needed to ensure they are safe to use over a length of time.

95 % safer – increasingly viewed as ‘harm reduction’

Growing numbers fires reported in UK– charger burnout, lighting e-cig plus oxygen. Reports of fatalities amongst children with e-liquids plus numerous cases of nausea and sickness

Calls for greater regulation

Concerns about big tobacco taking over the vaping industry

Smoking Cessation Outcomes Jan 14 – July 15

Referrals Patient Carers Staff Total

Reduced 557 6 14 577

Stopped 579 21 40 640

Re-started 12 0 0 12

Unchanged 74 2 6 82

Refused 1 0 0 1

Brief Interventions 3413 356 139 3908

TOTAL 4636 385 199 5220

Dan, aged 56yrs Head & Neck Cancer plus

Dementia (alcohol related) ‘Rollies’ 20+ per

day Completed alcohol detox

Daily radiotherapy / support with mask

Mucousitis, chest infection & loosing weight

Does use NRT inhalator when supervised

NRT Patches on his back

Successfully completed treatment

PEG cancelled as he was better able to eat & drink

Jan, 55, Breast Cancer Bought 100 cigs per day in S. Africa – down to 40 in UK ‘because of

cost’

On chemotherapy & radiotherapy planned

Advised to stop smoking to prevent recurrence/ new lung primary

Memory loss, peripheral neuropathy, breathlessness & very chesty

NRT inhalator, breathing techniques, hypnotherapy (3 sessions) & 6 short sessions for follow up.

Reduced to 20 by end of week 1 - smoke free by 6 weeks.

Disclosed rape in S. Africa – which she believed had triggered escalation in smoking. Attended counselling post treatment

Symptoms improved – able to walk without breathlessness

Recent Christie Study

(Pankhania et al, 2016)

Participants: Patients with lung cancer

(n=140) and family/friends (n=98)

Patients: 103 ex-smokers 31 current

smokers 5 smoked hookah 12 smoked

cannabis. 45 patients used an e-cig 12

dual use. 16 switching to e-cigs and/or

NRT inhalators.

Family/Friends: 38 ex-smokers. 17 current

smokers. 13 had stopped/reduced since

patient was diagnosed. 11 did not feel any

differently about continuing to smoke since

the patient’s diagnosis.

73% of smokers were given information about

the risks of smoking at GPs, 43% in

secondary care and 36% at specialist oncology

clinic.

46% of smokers were given advice about

cessation at GPs,12% in secondary care and

19% in oncology clinic.

87% of patients & 68% of family/ friends felt

differently about smoking since the diagnosis.

Role for HCPs

Always assess smoking status - patients expect to be

asked

Ask about e-cig /vaping usage – safety/comfort issues

Appreciate role of NRT to “manage” smoking during

hospitalization – a step towards becoming smoke free

Provide choices – patches, inhalators combinations

Seed for change …and repeat

Support colleagues to go smoke free

Stack up the positives/gains - improved response to

medication, tissue recovery etc.

Understand role of health advisors/ referral process

Next Steps Research with patients (and carers)

about their experience of NRT,

vaping & smoking cessation

Disseminate Proud2BSmoke Free

LGBT Report

Business case for continuing

Smoking Cessation services

Need for access to NRT for carers

and staff on hospital sites

Partnerships/Integration of hospital

smoking cessation services with

wider GM services

Beyond patients – seed change with

carers & staff – contribute to

reduction GM rates to 13% by 2021.

Our References

Heyworth, B. Roberts, L. Mackereth, P (2017) Proud2BSmokefree. LGBT Cancer Support

Alliance Manchester.

Mackereth, P. Fichett, C, Holt, M (2016) Smoke-free hospital site conversations: how nurses

can initiate change. British Journal of Nursing. 25(21) 1176-1180.

Pankhania, D. Coote, J. Burt, P. Mackereth, P.Finchett, C. Orrett, L. Hodgson, C. Bayman,

N. Blackhall, F. Califano, R. Chan, C. Faivre-Finn, C. Harris, M. Lee, L. Pemberton, L.

Sheikh H. Summers, Y. Taylor, P. (2016) Smoking habits in lung cancer patients and their

carers and audit of advice given. 14th Annual British Thoracic Oncology Group. Conference

Dublin.

Mackereth, P. (2015) Plain packs and more: towards a smoke-free future. British Journal of

Nursing. 24(5):134.

Mackereth, P. Maycock, P. Orrett, L. (2015) Smoke Free Site and service awareness

amongst hospital staff: a survey in an acute cancer centre. Journal of Hospital

Administration. 4(2): 43-47.

Stringer J Mackereth P Knowles R Finchett C Mannan J Slevin N (2015) Health advisor

facilitated mouth care regime for patients with head and neck cancers undergoing intensity

modulated radiotherapy. Journal of Radiotherapy in Practice. 14:353-361.

Mackereth P (2014) Focus on smoking cessation: Calm the craving in cancer care. Practice

Management. Sept Issue, 12-13.

Tomlinson L Mackereth P (2014) Smoking cessation dialogue and the complementary

therapist: Reluctance to engage? Complementary Therapies in Clinical Practice. 20: 181-

187.

Additional References

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Cataldo J Dubey S Prochaska J (2010). Smoking cessation: An integral part of lung

cancer treatment. Oncology, 78, 289-301.

Kaufman E Jacobson J Hershman D et al (2008) Effect of Breast Cancer Radiotherapy

and Cigarette Smoking on Risk of Second Primary Lung Cancer. Journal of Clinical

Oncology, 26(3), 392-399.

Lorigan P Radford J Howell A Thatcher N (2005). Lung cancer after treatment for

Hodgkin's lymphoma: a systematic review. Lancet Oncol, 6(10), 773-9.

Lorigan P Califano R Faivre-Finn C Howell A Thatcher N (2010) Lung cancer after

treatment for breast cancer Lancet. 11: 1184-92.

Parsons A Daley A Begh R Aveyard P (2010) Influence of smoking cessation after

diagnosis of early stage lung cancer on prognosis: systematic review of observational

studies with meta-analysis. BMJ. 340: b5569.

Robinson C Bottorff J Smith M Sullivan K (2010). Just because you’ve got lung cancer

doesn’t mean I will: Lung cancer, smoking and family dynamics. Journal of family Nursing

16: 282-301

Travis L Rabkin C Brown L et al. (2006) Cancer survivorship-genetic susceptibility and

second primary cancers: Research strategies and recommendations. Journal of the

National Cancer Institute 98(1):15–25