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The role of nurses in reducing the use of tobacco

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The fact that smoking is harmful to health is well known by both health professionals and the general public:


VOL: 100, ISSUE: 01, PAGE NO: 26

Ann Shuttleworth, BA, is a freelance health care journalist


The fact that smoking is harmful to health is well known by both health professionals and the general public:



- Over 120,000 people die from smoking-related conditions every year in the UK;



- Half of those who smoke for most of their lives die from the habit;



- An average of 16 years is lost from every smoker’s life expectancy (Department of Health, 1998).



Most people understand that smoking is the prime cause of cancer and heart disease, but it is less widely known that it can lead to or exacerbate a range of other fatal conditions and chronic illnesses (Box 1).



It is less that chewing tobacco also causes cancer. Some ethnic groups in the UK favour oral tobacco. For example, many people of South Asian origin chew tobacco, usually added to paan - a package of betel leaf, thinly sliced areca palm nut and lime paste. Many South Asian women believe it aids digestion and can relieve tooth or gum pain, and more than half of Bangladeshi women aged 55 and over regularly chew paan with tobacco (Department of Health, 2001).



Smoking cessation services
In order to combat the effects of tobacco use on the health of the population the government has funded a range of local and national smoking cessation services (Box 2). These services aim to encourage smokers to quit and to support them once they have decided to do so. The NHS Smoking Helpline offers callers non-judgemental advice and support from trained advisers, and also serves as a gateway to other sources of support. Callers can be referred to local cessation services, where they may be offered one-to-one or group support from trained smoking cessation advisers. Callers can also opt to receive e-mail support or choose from a range of literature giving advice and information.



The NHS ‘Giving up Smoking’ website contains information on the benefits of giving up, and other motivational aids such as a tool that enables smokers to calculate their lifetime expenditure on tobacco to date. It gives practical advice on giving up, as well as contact details for local smoking cessation services.



While most smoking cessation efforts target the general population, two groups are specifically targeted:



- The NHS Pregnancy Smoking Helpline was set up to encourage pregnant smokers - and their partners - to quit. Smoking and breathing in second-hand smoke during pregnancy can be harmful to mother and foetus (Gilliland et al, 2000; Blair et al, 1996; Poswillo and Alberman, 1992);



- The NHS Asian Tobacco Information Campaign aims to address tobacco use among Asian people and raise awareness of the associated health issues. The campaign funds a number of local support services and provides helplines in five Asian languages.



In addition to the support offered by helplines and other smoking cessation interventions, people who want to give up smoking can be offered nicotine replacement therapy (NRT) and/or bupropion on prescription. Following an appraisal of their effectiveness, the National Institute for Clinical Excellence (NICE, 2002) has recommended that they be prescribed to smokers (unless they are contraindicated) as part of abstinent-contingent treatment, in which the smoker sets a target stop date. There is little evidence that these interventions are effective for non-smoking tobacco users. Initial prescriptions should last only until two weeks after the agreed target stop date, and subsequent prescriptions should be issued only if the person can demonstrate that they are still trying to stop. NRT is also available over the counter in pharmacies.



Cessation targets
The support made available to tobacco users has shown impressive results to date. In 2001-2002, the target in England of 50,000 successful quitters at four-week follow-up (from self-reports) was exceeded comfortably, with 79,646 succeeding in the period April to December 2002 alone (DoH, 2002). The services have been set even more ambitious targets for this and the following three years. They are expected to achieve 100,000 quitters for 2002-2003, and a three-year target of 800,000 for the years 2003 to 2006 (DoH, 2003).



More specifically, the aim is to reduce the smoking rate among manual socioeconomic groups from 32 per cent to 26 per cent by 2010, and to achieve a one per cent reduction in the number of pregnant smokers each year. Extra funding has been made available to expand local smoking cessation support, as well as the NHS’s national services.



The nurse’s role



One of the most important groups to target in smoking cessation programmes is ‘well’ smokers and other tobacco users whose health has not yet been noticeably affected by their habit. Intervention by health professionals can be highly effective in persuading people to stop smoking (Raw et al, 1998), and many of these people will have contact with the health services for reasons unrelated to smoking. However, their smoking status may go unrecognised by most health professionals involved in their care and treatment.






The limited time available in consultations is often barely enough to discuss the issue with which the patient is presenting, let alone raise other subjects. Nurses often spend significant amounts of time with patients and may be in a position to raise the issue of smoking. Many primary care nurses and health visitors, whose work involves preventive health care and public health improvement, are aware of their potential role in reducing smoking rates. However, hospital-based nurses, who have the opportunity to develop relationships with patients over days or weeks, can also be effective in encouraging patients to quit smoking (Fiore et al, 1996).






Smoking cessation support can be a time-consuming process and requires specialist knowledge and skills, and nurses are not generally expected to provide such intensive input. While many nurses undergo training to enable them to develop local smoking cessation services, the most appropriate way for most nurses to contribute is through ‘brief interventions’. These can be undertaken as part of the admission procedure, during nursing assessment or while providing general nursing care. Nurses with prescribing qualifications can offer extra support by prescribing NRT or bupropion as well as referring people to specialist smoking cessation services.



Cessation services
Many smokers are unaware of the services set up to help them to stop smoking, so an effective intervention can be as simple as explaining how they can obtain support, giving them the contact details and encouraging them to take the first step. The message can be reinforced by explaining some of the lesser-known effects of smoking on health, while the dangers of second-hand smoke, such as increasing the risk of cot death, can be explained to those with children or grandchildren (Poswillo, 1998; Strachan and Cook, 1997) (Box 3). These interventions may give smokers new reasons to give up.



Brief interventions
The brief intervention generally involves assessing and recording the patient’s current smoking status. The way to proceed then depends on which of six ‘stages’ the patient is in - the aim being to encourage smokers to move on to the next stage towards giving up:



- Non-smokers can simply be congratulated and encouraged to resist any pressure to start (particularly in the case of young people);



- Smokers who are not interested in quitting can be told about the less well-known risks associated with smoking and the benefits of quitting, and offered appropriate literature in case they decide to quit in the future;



- Smokers who are thinking about giving up in the future can be encouraged to set a date and offered support and literature;



- Those who are ready to quit can be referred to their local NHS stop smoking service or encouraged to call the NHS Stop Smoking Helpline;



- Ex-smokers can be congratulated on their achievement and encouraged to maintain it;



- Smokers who have quit but have since relapsed can be encouraged to try again. They should be reassured that most people relapse a number of times before they quit for good, and that this is a normal part of the process. Such brief interventions are more likely to be effective if the patient can be given literature and contact details for smoking cessation services. A wide range of resources can be obtained free from the Tobacco Information Campaign (see Box 2).



Tobacco use is a major cause of morbidity and mortality. Smoking cessation programmes are government priorities to reduce both the human cost and the cost to the health service of smoking-related ill health.



As health care professionals who often have the greatest amount of contact with patients, hospital-based nurses are ideally placed to identify smokers before their habit causes lasting damage.



They can encourage these smokers to consider quitting. In addition, they can direct them on to specialist smoking cessation services.



Nurse prescribers can also prescribe NRT or bupropion where appropriate in order to help smokers to stop, provided they have demonstrated sufficient commitment by setting a target date to quit.



- This article has been double-blind peer-reviewed.

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