VOL: 98, ISSUE: 40, PAGE NO: 66
Jennifer Percival, RN, RM, RHV FETC, Dip Counselling, is tobacco education project manager, RCN, London
Providing help to stop smoking is an extremely valuable use of a nurse’s time. However, for many this work is not rewarding and they become disillusioned if people start smoking again. It is important to recognise that the success rates for people quitting without help is only 2-3%, but if smokers use professional help and nicotine replacement therapy (NRT) or bupropion, the rate may rise to 20-30% (Buck and Godfrey, 1994). The chances of giving up smoking in the long term increases with more intensive support (West et al, 2000).
Why is it hard to stop smoking?
Smokers have to understand the part smoking has played in their lives and be able to work out ways of living as a non-smoker. Three different factors play a part: physical addiction to the drug nicotine, the ritual or habit and the psychological/emotional dependence (Royal College of Physicians, 2000).
Many smokers have withdrawal symptoms as nicotine leaves their body (Royal College of Physicians, 2000). These withdrawals can make it hard for them to continue their attempt. It is important to discuss the possible symptoms and explain how NRT or bupropion can help.
Withdrawal symptoms may include:
- Craving - an intense desire to smoke, which typically lasts two to three minutes. This becomes less frequent and intense over a period of weeks. Suggest distraction, drinking water and taking some slow, deep breaths;
- Increased appetite - this is due to the lack of nicotine, which tends to suppress appetite. The combined effects of changes in the metabolism, increased appetite, improved sense of taste and replacing cigarettes with snacking cause weight gain. Suggest clients eat less high-calorie foods and increase their level of exercise;
- Tearfulness, anxiety, irritability and loss of concentration - all attributed to the upheaval of breaking a long-established habit and the withdrawal symptoms. Some smokers go through a ‘grief’ process for a few months;
- Sleep disturbance - difficulty in sleeping or staying awake. It is not uncommon to have an initial week of sleeping badly, followed by a week of difficulty staying awake. Vivid dreams are also common;
- Worsened cough - the cilia function more effectively, increasing removal of secretions from the lungs, which can cause a temporary cough;
- Light-headed or dizzy feelings may occur as the level of carbon monoxide in the blood starts to fall and oxygen to the brain increases;
- Sore tongue and mouth ulcers - probably a result of chemical and bacterial changes in the mouth;
- Constipation - tobacco has a laxative effect which the bowel adapts to.
The National Institute for Clinical Excellence (NICE) has issued guidance on the use of NRT and bupropion (Zyban) for smoking cessation (National Institute for Clinical Excellence, 2002). The review shows that the main smoking cessation treatments - NRT and bupropion - are among the most cost-effective of all health care interventions and represent extremely good value for money for the NHS. They recommend that NRT or bupropion should be prescribed in conjunction with advice and support.
Nicotine replacement therapy
All NRT products are designed to help people stop smoking without experiencing withdrawal symptoms. NRT is absorbed by the body in a different way to nicotine from cigarettes and so is much less addictive. People who use the full 10-12-week course achieve the best results. NRT does not provide a complete replacement for cigarettes, nor replaces the need for willpower, but it helps people cope with their cravings.
NRT products are included in the Nurse Prescribers’ Formulary, and many nurses can supply NRT under patient group directions.
All current NRT products have a similar success rate, and the choice between them is a practical and personal one (West et al, 2000). The patch is easiest to use, but the other formulations give a smoker more control over the dose and the speed of absorption. All types of NRT are available over the pharmacy counter. Gum, patches and lozenges are also on general sale in shops and supermarkets.
Nicotine patches work by giving a constant supply of nicotine. The 24-hour patch helps avoid cravings on waking but can cause sleep disturbances. The 16-hour patch is ideal for regular smokers. Moving the patch site daily will help prevent skin irritation.
Nicotine gum gives nicotine on demand which is absorbed through the lining of the mouth. A chew-rest-chew technique is best because any nicotine swallowed is wasted and can irritate the gut. The gum should be held between the cheek and gum between chews.
Nicotine nasal spray is the strongest form of NRT available. Nicotine taken in this way is absorbed quickly, so is especially suited to people experiencing severe withdrawal symptoms or those who have high nicotine dependence. The spray can irritate the nose at first, but this quickly passes.
The inhalator is a plastic device shaped like a cigarette into which a nicotine cartridge fits. You suck on the mouthpiece to release a nicotine vapour, which gets absorbed through the mouth and throat. The inhalator is useful for people who miss the hand-to-mouth action of smoking.
The microtab is a small tablet containing nicotine that dissolves under the tongue. It should not be sucked, chewed or swallowed as this reduces the amount of nicotine absorbed.
The lozenge is like a sweet that is left dissolving in your mouth. It delivers nicotine in a way similar to the microtab.
Although using pharmacotherapy doubles a person’s chance of success, most people who quit smoking do not use anything (West et al, 2000). Underuse of NRT is a common problem, and nurses should encourage smokers to use the full daily amount and to continue the course for 10-12 weeks. The dosage can be reduced when they feel confident. This will vary according to the individual’s preference.
Who cannot use NRT?
NRT is currently licensed for use by smokers over 18. There are warnings for pregnancy and coronary disease, but in most cases it is likely that using a course of NRT to assist quitting will be safer than continued smoking (West et al, 2000). In these cases people will need to have their conditions assessed by their doctor and any other medications monitored when using NRT.
Bupropion hydrochloride (Zyban) is an effective non-nicotine treatment which has helped many smokers to stop. The treatment, which is in tablet form, lasts two months, with smokers stopping smoking during the second week of the course. Zyban reduces the desire to smoke and withdrawal symptoms. It is not suitable for everyone and is only available on prescription. A full medical history needs to be taken before it is prescribed.
How to give a patient practical help
Prochaska and DiClemente (1983) suggest that stopping smoking is not a single event but a process in which the smoker goes through a series of five predictable stages: pre-contemplation, contemplation, preparation, action/maintenance and possible relapse.
It is important to assess clients’ readiness to change. At each stage it is important to help patients to think about their own situation and personalise their plans for giving up. This involves asking the right questions (Box 1).
Many smokers hope that NRT will work like magic and replace the need for willpower. Unfortunately, without preparation people are unlikely to succeed. You may need to check your patient’s motivation before offering NRT. NICE suggest prescribing an initial two weeks of NRT, with further prescriptions being given if patients are motivated to continue their quit attempt (National Institute of Clinical Excellence, 2002).