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Helping patients with Crohn's disease to stop smoking

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Susanna Challis, BSc (Hons), RGN.

Was Smoking Cessation Specialist Advisor, Poole Hospital NHS Trust, when this paper was written. She is now Smoking Cessation Specialist Advisor, South and East Dorset PCT, Ferndown, Dorset

Awareness of the link between the worsening of Crohn’s disease and smoking (Sommerville, 1984) prompted nurses in one general hospital to embark on a project to evaluate the effectiveness of a smoking-cessation clinic targeted specifically at patients with Crohn’s disease.

 

Awareness of the link between the worsening of Crohn’s disease and smoking (Sommerville, 1984) prompted nurses in one general hospital to embark on a project to evaluate the effectiveness of a smoking-cessation clinic targeted specifically at patients with Crohn’s disease.

 

 

The project took the form of an observational study. Individuals with Crohn’s disease, identified as smokers during outpatient appointments, were given verbal information about the effects of smoking on their condition and were invited to attend a series of smoking-cessation sessions. This was followed up by a written invitation to attend. Relevant literature was researched using the hospital and university libraries, and nursing and medical internet sites.

 

 

Literature review
There is increasing evidence of the role of smoking in the pathogenesis of inflammatory bowel disease. Smoking is not only a risk factor for the development of Crohn’s disease; ongoing smoking is associated with a worse disease course. Sommerville made the initial observation in 1984, yet very few studies explore the implementation of smoking cessation as a treatment strategy.

 

 

Chronic illness is a multidimensional experience and while not a desirable state, it is a life experience with which some people must cope (Rowlinson, 1999). Inflammatory bowel disease, in particular Crohn’s disease, falls into this definition. It involves a permanent alteration to the individual’s way of life and a reappraisal of what may be hoped for in terms of function and health (Cluff, 1981). Crohn’s disease may be defined as a chronic inflammatory disorder characterised by patchy granulomatous inflammation of any part of the gastrointestinal tract.

 

 

Over the past decade, substantial gains have been made in the treatment of Crohn’s disease. Refinements in drug formulation have provided the ability to target distinct sites of delivery, enhancing their safety and efficacy.

 

 

In subsequent studies to that of Sommerville (1984), Franceschi et al (1987) and Silverstein (1989) demonstrated a greater risk of Crohn’s disease in current smokers than non-smokers. A meta-analysis on seven suitable studies of Crohn’s disease confirmed a pooled odds ratio of 2.0 for current smokers compared with lifetime non-smokers and 1.83 for former smokers compared with lifetime non-smokers. In this ex-smoking group the risk was greater for those who had quit smoking within four years before developing Crohn’s disease and least for those who had been non-smokers for more than 10 years (Calkins, 1989). The site of Crohn’s disease has been weakly linked with the duration of smoking habit and number of cigarettes smoked. Small bowel and ileo-colonic disease are more common in heavy smokers (Lindberg et al, 1992).

 

 

Smoking also appears to have an adverse effect on the clinical course of the disease (Thomas et al, 2000). Cottone et al (1994) studied the influence of smoking on the clinical course of Crohn’s disease in 182 patients followed up over a 20-year period. After surgery, the risks of clinical, endoscopic and surgical recurrence were all increased in smokers compared with non-smokers. Furthermore, in a study on the effect of smoking on the quality of life of patients with Crohn’s disease, young females who continued to smoke suffered more bowel and systemic symptoms, in addition to more emotional dysfunction, than female non-smokers with Crohn’s disease (Russel et al, 1996).

 

 

Latterly, Cosnes et al (2001) performed an intervention study evaluating the benefit of smoking cessation in individuals with Crohn’s disease: 474 consecutive smokers with Crohn’s disease were given repeated counselling to stop smoking and easy access to a smoking-cessation programme. The findings were consistent with the literature and established that patients with Crohn’s disease who stop smoking for more than a year run a no more aggressive disease course than those who have never smoked (Cosnes et al, 2001).

 

 

Although non-smoking is not a panacea for Crohn’s disease, the evidence clearly suggests that patients with the condition should be encouraged to cease the habit. A questionnaire survey by Shields and Low-Beer (1996) found that many GPs and their patients with Crohn’s disease were unaware that smoking influences the incidence and course of the disease. Hecht et al (1994) found that patients who received information from doctors, with additional nursing interventions, were more likely to make serious attempts to stop smoking than those who received doctors’ advice alone.

 

 

Evidence into practice
Many factors affect the decision of when and how to intervene in the management of a patient. A multitude of factors in addition to knowledge of the most effective treatment option affect decisions of when and how to intervene. These factors include patient demand and high patient expectations, ‘tradition’, financial implications, feasibility and availability of clinical investigations, the therapeutic imperative, concerns about litigation and even media pressure. Research evidence may be one of the last factors considered despite the fact that the results of good clinical trials can provide the best evidence upon which to base effective therapeutic decisions (Johanson and Rigby, 1999).

 

 

To be of any value, research evidence needs to be put into practice. Cochrane (1972) proposed the view that good decisions about health care rely on more than good reviews of the results of research. Cochrane suggests that, if better decisions are to lead to improved health, then effective mechanisms are needed for implementing them efficiently.

 

 

The challenge that faces all health-care professionals is putting the evidence into practice. Various models of implementation have been devised. The simplest is merely a dissemination of research information and the next is to employ a credible dissemination body to distil the research information and distribute it (Lomas, 1993). Changing practice through the development of local guidelines is thought to be more effective than either of these (Grimshaw, 1993).

 

 

Smoking Kills initiative
In December 1998 the Government launched the White Paper Smoking Kills (DoH, 1998) and collaborated with health professionals to produce guidelines to help people stop smoking. As part of the initiative, the past two years has seen the establishment of specialist smoking services in every health authority/primary care trust throughout England. Early indications demonstrate a smoking cessation rate of 60-70% after four weeks of clinic attendance and 20-25% of smokers remain abstemious a year later. This compares to 1% of smokers who have a lone attempt at cessation (Cresswell, 2000).

 

 

Clinical governance
Cochrane (1972) highlights the basic principles of effectiveness and efficiency. Cochrane recommends that forms of care which have demonstrated positive beneficence be encouraged, those demonstrating more harm than good be discarded, and those that have unknown effects be tested, as far as possible, as part of research studies to ascertain whether or not they are effective.

 

 

With the advent of clinical governance, NHS organisations are now accountable for continuously improving the quality of their services and safeguarding high standards of care. It has become an inescapable responsibility of the chief executive and trust board (Johanson and Rigby, 1999). The issues of leadership and motivation are fundamental to the success of quality programmes and the provision of a specialist level of service. A smoking-cessation clinic, aimed at patients with Crohn’s disease, may be a mechanism to put the evidence into practice.

 

 

The authors believed that encouraging patients to cease smoking ought to be an important part of the management of Crohn’s disease. However, research evidence needs putting into practice and effective mechanisms are required for implementing research efficiently. There is little doubt of the overall impact of smoking on general health and the benefits of smoking cessation.

 

 

The pilot study
Population

 

 

This work was based in the gastroenterology department of one general hospital; consequently the sample was small. During a period of six months 14 smokers with Crohn’s disease were identified. All were subsequently invited to attend seven-week ‘SmokeStop’ courses. The local programme is based on the national smokingcessation guidelines for health professionals (West et al, 2000). Seven referrals (50%) requested help to stop smoking. Six patients attended courses and one patient was seen individually because of long-term hospitalisation for her Crohn’s disease. Permission for inclusion in the study was sought from each individual.

 

 

The remaining seven smokers continued with their treatment with the offer of access to professional smoking-cessation support at any time. Three of the smokers indicated that they enjoyed smoking and did not believe this to be a relevant factor in their medical condition. According to the ‘Stages of Change’ model (Prochaska and Di Clemente, 1983) these contented smokers are in the ‘precontemplation’ stage and may move into the ‘contemplation’ stage at any time, followed by ‘action’ then either ‘maintenance’ or ‘relapse’.

 

 

Pharmacotherapy

 

 

Raw et al (1998) state that appropriate pharmacotherapy, in addition to behavioural support, offers the greatest chance of quitting smoking. Information regarding nicotine replacement therapy (NRT) and bupropion (Zyban) was presented to each group at the introductory session. Bupropion is not contraindicated in patients with Crohn’s disease. This drug was originally developed as an antidepressant and it is not known exactly how it suppresses the urge to smoke.

 

 

Nicotine is the addictive component of tobacco. NRT delivers a controlled dose of nicotine to enable the smoker to break the habit of smoking while cutting down gradually on the amount of nicotine used. There are several NRT products, which are listed in Box 1.

 

 

All the products are available on prescription and should be discontinued after three months. According to the National Institute for Clinical Excellence (2002), bupropion and NRT are among the most cost-effective of all health-care interventions.

 

 

Smoking-cessation sessions

 

 

After being given information on the pharmacotherapy available, the participating patients were encouraged to choose a product with the guidance of the course facilitator. The individuals were provided with a letter to their GP requesting a two-week prescription. Further letters were issued at two-weekly intervals to ensure continued participation in the course. Three smokers used bupropion, two patches and one used the nasal spray. The hospitalised patient preferred not to use a product.

 

 

Carbon monoxide (CO) levels in exhaled air were measured with the use of a ‘Smokerlyser’. CO is measured in parts per million (ppm): 6ppm roughly equates to 1% carboxyhaemoglobin in the blood. During the following two weeks participants were encouraged to prepare psychologically for stopping smoking by keeping a smoking diary and recording the ‘pros and cons’ of smoking. The third session was agreed upon as the quitting date.

 

 

Lifestyle choices

 

 

The sessions relied heavily on group support with the guidance of a facilitator. Group members were encouraged to replace the unhealthy smoking habit with healthier lifestyle choices. Each week the facilitator presented one aspect of a healthy lifestyle. The topics included: stress management, relaxation, healthy eating, weight control and exercise.

 

 

The health education emphasis encouraged one Crohn’s patient to make several lifestyle changes. She had attended the course with her partner, who also succeeded in stopping smoking. They reassessed their diet and began to eat more healthily, joined a gym and bought mountain bikes with the money they were saving from not smoking. The combination of healthy eating and increased exercise resulted in weight loss and the encouragement to remain ex-smokers.

 

 

An additional benefit of increasing exercise when stopping smoking was demonstrated by a randomised controlled trial (Ussher et al, 2001). The results show that increasing moderate exercise lessens withdrawal symptoms and reduces the desire to smoke. Further assistance can be gained in reducing withdrawal symptoms by using glucose supplementation (West, 2001). Many of the Crohn’s patients found 4-5 glucose tablets a day helpful. This is based on the premise that smoking changes the way carbohydrate is regulated by the body. During quitting there is an increased desire for carbohydrates - glucose satisfies this need rapidly, and quitters report that this reduces the desire to smoke. Trials are under way to test this theory (West, 2001).

 

 

During the final session of the course all participants were tested again for CO level to validate their non-smoking status. A reading of less than 10ppm is accepted as proof of cessation.

 

 

Results
- Half the referrals (seven) decided to quit smoking

 

 

- Six of these used pharmacotherapy; one did not

 

 

- Six achieved non-smoking status at four weeks.

 

 

Four weeks after the course ended one of the patients relapsed. This patient suffered from a variety of other health problems in addition to social problems and became depressed during the course. He decided not to continue with his attempt at that time. According to Prochaska and Di Clemente (1983) some smokers will relapse and need to progress round the cycle again before they are able to maintain their non-smoking status. The other six remained ex-smokers, confirmed by telephone three months after quitting.

 

 

Discussion
The four-week quitting rate of 86% showed a higher rate of success among this population of smokers, compared with a rate among the general population of 60-70% (DoH, 2002). However, it is acknowledged that it was a very small sample. The higher rate of success may have been because the participants were very motivated to stop smoking once aware of the direct adverse effect of smoking on their condition. Any positive action that offers a better quality of life may provide sufficient motivation to meet their goal. The inclusion of alternative healthier lifestyle choices as part of the course further motivated these individuals as they became aware of definite improvements in their symptoms and general health.

 

 

It would appear that patients are more likely to consider making an attempt to stop smoking if the information of the effect of smoking on Crohn’s disease is presented by more than one source (Sercombe, 2000).

 

 

Presenting the information on the effects of smoking on the disease course of these patients enabled them to have a choice. Half chose to comply and made changes to their lifestyles during the course. During the three-month telephone follow up these individuals all reported increased self-esteem and fewer symptoms with overall better health: they were fitter and able to be more active.

 

 

Summary
Evidence shows that smoking causes Crohn’s disease to run a more aggressive disease course (Thomas et al, 2000). Anecdotally, individuals with Crohn’s disease who are given appropriate information and make the decision to quit their smoking habit seemed well motivated to stop. The individuals who decided not to stop smoking were given the information and access to the specialist adviser if they wish to seek help in the future. On publication of this paper it is too early to say if stopping smoking has impacted on the disease course; however, the results so far appear encouraging. The patients will be monitored during routine outpatient appointments with the gastroenterology nurse specialist. Any individual who relapses will be referred back to the smoking-cessation adviser.

 

 

Recommendations
In order to put research into practice it is necessary to have effective mechanisms of support in place. These include qualified and skilled professionals, appropriate venues and resources such as Smokerlysers and information sheets. Smoking cessation is a cost-effective treatment option and should be made available to all patients with Crohn’s disease. It may impact on the use of steroid and immunosuppressive treatments and, subsequently, cost implications. If the knowledge of the impact of smoking on Crohn’s disease becomes more widespread among health professionals more patients may be inclined to attempt to quit the habit.

 

 

Implications for the future
The observational study was based on a very small population therefore further studies are needed. Crohn’s disease symptoms will be monitored in the inflammatory bowel disease clinic using outpatient appointments and hospital admissions to assess stopping smoking as a treatment strategy. General health improvements could be formally evaluated using a quality-of-life questionnaire.

 

 

On the basis of the results of this study, similar smoking-cessation services for patients with Crohn’s disease are to be considered for the other two general hospitals in the area.

 

 

Further reading
Bollinger, C. (2002)
Practical experiences in smoking reduction and cessation. Addiction 95: 19-24.

 

 

Campbell, A. (2000)Smoking cessation. Thorax 55: 28-31.

 

 

Kunze, M. (2000)Maximizing help for dissonant smokers. Addiction 95: 13-17.

 

 

Logan, R. (1987)Inflammatory Bowel Disease: Basic research and clinical implications. Lancaster: MTP Press.

 

 

Acknowledgement
The authors would like to thank Dr Jonathon Snook and Dr Paul Harker for their encouragement and support

 

 

 

 

Calkins, B. (1989)A meta-analysis of the role of smoking in inflammatory bowel disease. Digestive Disease Science 34: 1841-1855.

 

 

Cluff, L.E. (1981)Chronic disease function and the quality of care. Journal of Chronic Disease 34: 7, 229-304.

 

 

Cochrane, A. (1972)Effectiveness and Efficiency. London: Nuffield Provincial Hospitals Trust.

 

 

Cosnes, J., Beaugerie, L., Carbonnel, F., Gendre, J.P. (2001)Smoking cessation and the course of Crohn’s disease: an intervention study. Gastroenterology 120: 5, 1093-1099.

 

 

Cottone, M. (1994)Smoking habits and recurrence in Crohn’s disease. Gastroenterology 106: 643-648.

 

 

Cresswell, J. (2001)Smoking cessation and cancer: ways of discovering tobacco use. Professional Nurse 16: 6, 1141-1143.

 

 

Department of Health. (1998)Smoking Kills (White Paper). London: The Stationery Office.

 

 

Department of Health. (2002)Smoking Cessation. London: The Stationery Office.

 

 

Franceschi, S., Panza, E., La Vecchia, C. et al. (1987)Non-specific inflammatory bowel disease and smoking. American Journal of Epidemiology 125: 3, 445-452.

 

 

Grimshaw, J. (1993)Effect of clinical guidelines on medical practice: a systemic review of rigorous evaluations. Lancet 342: 1317-1323.

 

 

Hecht, I.P., Emmons, K.M., Brown, R.A. et al. (1994)Smoking interventions for patients with cancer: guidelines for nursing practice. Oncology Nurse Forum 21: 10, 1657-1666.

 

 

Johanson, R.B., Rigby, C. (1999)Clinical governance in practice: achieving sustainable quality in maternity. Journal of Clinical Excellence 1: 19-22.

 

 

Lindberg, E., Jarnerot, G., Huitfeldt, B. (1992)Smoking in Crohn’s disease: effect on localisation and clinical course. Gut 33: 6, 779-782.

 

 

Lomas, J. (1993)Retailing research: Increasing the role of evidence in services for childbirth. Milbank Quarterly 71: 439-475.

 

 

National Institute for Clinical Excellence. (2002)Guidance of Use of Nicotine Replacement Therapy and Bupropion. London: NICE.

 

 

Prochaska, I, Di Clemente, C. (1983)Stages and processes of self-change of smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology 51: 3, 390-395.

 

 

Raw, M, Jarvis, M., Sutherland, G. et al. (1998)Smoking Cessation Taskforce. Available at: www.smokingcessation.co.uk.

 

 

Rowlinson, A. (1999)Inflammatory bowel disease: importance of partnership in care. British Journal of Nursing 8: 15, 103-108.

 

 

Russel, M.G., Nieman, F.H., Bergers, J.M., Stockbrugger, R.W. (1996)Cigarette smoking and quality of life in patients with inflammatory bowel disease. European Journal of Gastroenterology 8: 11, 1075-1081.

 

 

Sercombe, J. (2000)Inflammatory bowel disease and smoking. Professional Nurse 15: 7, 439-442.

 

 

Shields, P.L., Low-Beer, T.S. (1996)Patients’ awareness of adverse relation between Crohn’s disease and their smoking: questionnaire survey. British Medical Journal 313: 7052, 265-266.

 

 

Silverstein, M. (1989)Cigarette smoking in Crohn’s disease. American Journal of Gastroenterology 84: 31-33.

 

 

Sommerville, K.W., Logan, R., Edmond, M., Langman, M.J. (1984)Smoking and Crohn’s disease. British Medical Journal (Clinical research edn) 289: 954-956.

 

 

Sutherland, G., Stapleton, J.A., Russell, M.A. et al. (1992)Randomised controlled trial of nasal nicotine spray in smoking cessation. Lancet 340: 8815, 324-329.

 

 

Thomas, G.A.O., Rhodes, J., Green, J.T., Richardson, C. (2000)Role of smoking in inflammatory bowel disease: implications for therapy. Postgraduate Medical Journal 76: 273-279.

 

 

Ussher, M., Nunziata, P., Cropley, M., West, R. (2001)Effect of a short bout of exercise on tobacco withdrawal symptoms and desire to smoke. Psychopharmacology 158: 1, 66-72.

 

 

West, R. (2001)Glucose for smoking cessation. CNS Drugs 15: 261-265.

 

 

West, R., McNeill, A., Raw, M. (2000)Smoking cessation guidelines for health professionals: an update. Thorax 55: 987-999.

 

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