Gillian Bruce explores the positive role of smoking cessation services in hospitals
This is an online-only article published June 26, 2008
Gillian Bruce, MN, RGN, BN, Dip smoking cessation, is lead smoking cessation nurse specialist, Forth Valley Acute Services, Forth Valley, Scotland and Chair of the British Association of Stop Smoking Practitioners.
All smokers who are admitted to hospital should be given information about smoking cessation (NICE, 2008). This is particularly important if they are admitted due to a smoking-related condition such as chronic obstructive pulmonary disease, ischaemic heart disease or a stroke, as stopping smoking will significantly reduce their risk of repeated admissions and premature death (Department of Health, 1999).
Stopping smoking is difficult at any time, and usually takes more than one attempt. Providing support and treatment will significantly increase the chances of success – from 2% to 20% (Health Scotland and ASH Scotland, 2004).
Many hospitals are now developing on-site smoking cessation services, to coincide with the legislation on smoking in public buildings.
Smoking cessation services in hospital
Hospital-based smoking cessation services are recommended by the British Thoracic Society (2003), Smoking Cessation Guidelines for Scotland (Health Scotland and ASH Scotland, 2004, Updated 2007) and NICE (2002; 2008) and have been shown to be successful (Rigotti et al, 2007). It is important that any hospital-based service is integrated with the community it serves, as many patients will move between primary secondary care. Knowledge of the referral pathways to each service is invaluable.
Function of the smoking cessation service in hospital
The hospital-based smoking cessation service has a number of functions. Some patients may be referred with withdrawal symptoms, but may not want to stop smoking. Many NHS settings are smoke-free (including grounds) and patients who are unable to smoke may experience withdrawal from nicotine and this should be treated like any other dependence. These services may also see patients prior to surgery, and those attending out-patient clinics such as respiratory and cardiac rehabilitation.
Withdrawal following hospital admission
All patients should have their smoking status recorded, and be given brief advice about the benefits of stopping and referral on to a specialist service (NICE, 2008). Healthcare professionals should use any patient contact as a chance to provide opportunistic advice to their patients about their smoking status. They should therefore be aware of the local smoking cessation services and how to refer patients.
Withdrawal from nicotine needs to be recognised and treated appropriately in the acute hospital. It will often be the ward nurses who are relied on to recognise the symptoms and make the appropriate referral (Box 1). They may be asked to instigate therapy while waiting for the patient to be seen by specialist services and assessed more fully. However, not all patients will experience all symptoms of withdrawal.
Box1. Symptoms of withdrawal - cravings
Management of withdrawal
The main treatment of choice for withdrawal in the acute setting is nicotine replacement therapy (NRT). This should be started as soon as possible following admission. Dependence on nicotine can be assessed using the Fragerstorm Scoring (Heatherton et al 1991).
Nicotine replacement therapy
There is a wide range of NRT including patches, gum, inhalator, lozenges, microtabs and nasal spray. Patients can combine different products and the treatment should last for at least 10 weeks.
There are relatively few side-effects of NRT and it is important to remember that patients were taking nicotine already through their cigarettes.
The 24-hour patch may cause sleep disturbance, and other common side-effects of NRT are headache, palpitations and gastro intestinal disturbances. Some patients who have skin disorders such as psoriasis or eczema may experience skin problems with patches and those with an active stomach ulcer should not use the gum.
Stopping smoking, with or without NRT, affects the body’s metabolism and for that reason specific drugs, including theophylline, warfarin, and clozapine, require careful monitoring. Patients with diabetes should also monitor their blood glucose levels closely.
Patients with ischaemic heart disease benefit from a 16-hour NRT patch which allows ‘nicotine-free’ time during which the vasoconstriction caused by nicotine is reduced.
Bupropion and varenicline
Prescription-only medicines for smoking cessation are bupropion (Zyban) and varenicline (Champix).Bupropion has been used as an antidepressant but its mode of action in smoking cessation is not clear and may involve an effect on noradrenaline and dopamine neurotransmission. Varenicline is a selective nicotine receptor partial agonist (BNF, 2008). Both these drugs must be taken for just over 1-2 weeks so a therapeutic level is reached before the patient stops cigarettes. For this reason they are not widely used in acute settings. Dry mouth and insomnia are fairly common side-effects of bupropion, while the most common side-effect of varenicline is nausea.
Intervention by a smoking cessation practitioner to look at alternative coping mechanisms can increase patients’ confidence and those who are initially treated for withdrawal may move to a quit attempt.These practitioners use motivational interviewing to discuss smoking with patients who, prior to admission, were not thinking about stopping smoking. The technique was introduced by William Miller in 1983, and uses an evidence-based counselling approach to promote changes in behaviour by assisting patients to explore and then resolve their own ambivalence. Levensky et al (2007) described the four principles of this approach:
Develop a discrepancy;
Roll with resistance;
He also identified four skills required to implement the technique:
Asking open-ended questions;
Motivational interviewing is a useful tool for patients who are determined to continue smoking to help them explore this choice. It is useful to investigate their barriers to quitting and find solutions. Asking open-ended questions such as ‘What do you enjoy about your cigarettes?’, ‘Have you tried stopping before, with support and treatment?’ can involve patients in a discussion about their smoking and hopefully increase their motivation and confidence to stop. Box 2 lists the benefits of smoking cessation.
Box 2. The benefits of stopping smoking
|After 20 mins|
Patients should be discharged with therapy and advised on continuing it in the community.
Hospital-based smoking cessation services can provide support during patients’ stay and liaise with the appropriate community service to provide ongoing support and treatment. Patients may prefer to continue to use the hospital service as out-patients or via telephone support. It is important that they know how this is going to work prior to discharge, as patients often relapse after discharge from hospital.
It is important that all patients are followed up according to local/national guidelines. In Scotland an online national database is used by all specialist services and there are specific time points when patients are contacted and smoking status recorded – these are four weeks, 12 weeks and 12 months. This ensures that all services measure and record information in the same way and it can be used to audit quit rates for individual services as well as health board areas.
In England PCTs audit services differently, and smoking cessation practitioners need to be aware of the local policies.
Developing hospital services
The British Thoracic Society has produced guidelines on the level of service that should be provided by hospital-based smoking cessation services (BTS, 2003). It has also produced a toolkit to help NHS staff meet a basic set of core competencies to identify and support smokers who want to stop smoking. This is available to download directly from the BTS website www.brit-thoracic.org.uk(BTS, 2007).
West (2006) notes that although providing cessation support and treatment to smokers within the UK created 90,000 ex-smokers in 2005, the total effect on smoking prevalence in the UK was in the region of a 0.2% reduction. Cessation support and treatment, while important, is only a small part of the wider tobacco control picture. However, hospital staff can make a difference, and a hospital-based cessation service can have an impact on patients’ lives.
British Thoracic Society (2003) Recommendations for Hospital-based Smoking Cessation Services.http://www.brit-thoracic.org.uk/ClinicalInformation/SmokingSmokingCessation/tabid/113/Default.aspx
British Thoracic Society (2007) Core Competencies – Health Professionals and Tobacco. A Toolkit.
British Medical Association, Royal Pharmaceutical Society (2008) British National Formulary. London: BMA and RPS.
Department of Health (2003) Giving Up for Life. London: DH.
Department of Health (1999) Smoking Kills. A white paper on Tobacco. London: Stationery Office.
Levensky, E.R. et al (2007) Motivational interviewing: An evidence-based approach to counselling helps patients follow treatment recommendations. American Journal of Nursing; 107: 10, 50–58.
Health Scotland and ASH Scotland (2007) Supplement to the 2004 Smoking Cessation Guidelines for Scotlandhttp://www.healthscotland.com/uploads/documents/3985-Smoking_cessation_update_2469_32207.pdf
Heatherton, T.F. et al (1991) The Fragerstrom test for nicotine dependence; a revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction; 86: 9, 1119–1127.
National Institute for Health and Clinical Excellence (2002) Technology Appraisal No 39. Guidance on the use of NRT and Bupropion for smoking cessation.www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=11452
National Institute for Health and Clinical Excellence (2008) Public Health Guidance 10. Smoking Cessation Services in Primary Care, Pharmacies, Local Authorities and Workplaces, Particularly for Manual Working Groups, Pregnant Women and Hard to Reach Communities.www.nice.org.uk/guidance/index.jsp?action=byID&o=11925
RCN (2007) Clearing the Air 2 Smoking and tobacco control- an updated guide for nurses. www.rcn.org.uk/__data/assets/pdf_file/0011/78554/001945.pdf
Rigotti, N.A. et al (2007) Interventions for Smoking Cessation in Hospitalised Patients. Cochrane Database of Systemic Reviews 2007, Issue 3. Art.No.:CD001837.DOI
West, R. (2006) Tobacco control: present and future. British Medical Bulletin, 77-78: 1, 123-136; doi:10.1093/bmb/ldl012