VOL: 101, ISSUE: 10, PAGE NO: 26
Ben Youdan, is chief executive of the charity No Smoking Day
Bridget Queally, Bsc, RM, is freelance smoking cessation trainer
Smoking is one of the biggest threats to public health, costing more than 120,000 lives per year in the UK alone (Peto et al, 2004).
Stopping smoking is the single most important step patients can take to improve their health, and ensuring they receive appropriate support to do so can make a huge difference to their chances of success.
Nurses have wide access to patients in many settings, from the community to the hospital, and are in frequent contact with smokers. They may feel they lack the counselling skills to persuade smokers to stop but there are many simple ways in which they can encourage them to seek help. For example, they can refer patients to smoking cessation services or offer information on such services or national campaigns such as No Smoking Day.
Smokers have a one-in-two chance that their habit will kill them. More than 50 illnesses are caused or exacerbated by smoking and more than 20 fatal conditions are caused by cigarette use (Action on Smoking and Health, 2004). Despite the risks and dangers associated with smoking, however, there are still 12 million smokers in the UK (25 per cent of the UK adult population). Two-thirds of these say they would like to stop yet very few succeed on their first attempt.
The Royal College of Physicians acknowledges that the nicotine in cigarettes is as addictive as crack cocaine (RCP, 2000). Nicotine addiction is the primary reason people continue to smoke. It is important to make the distinction between smoking as a habit and as an addiction, as it has major implications on how smokers are perceived. Helping smokers to stop requires treatment for addiction. Nurses are in an ideal position to offer this.
The impact of smoking on health care
It is estimated that treating smoking-related illness costs the NHS £1.7bn per year (Parrot et al, 1998), over half of this cost being due to the treatment of smoking-related cancers and circulatory diseases. An average of 1,000 hospital admissions per day are attributable to smoking.
Nurses have a huge role to play in caring for these patients and a massive amount of nursing resources goes into providing this care. Measures to help smokers stop are highly cost-effective. For example, the cost of brief advice about stopping smoking per adjusted life year is £126, the cost of a smoking cessation service is £658 and the cost of No Smoking Day is £26 (Parrot and Godfrey, 2004). This compares with reported NICE recommendations for health spending of £30,000 per life year.
Smoking is high on the public health agenda, with government targets to reduce UK smoking rates from 28 per cent of all adults to 24 per cent by 2010. Plans to meet these targets have taken a comprehensive approach including setting up dedicated NHS smoking cessation services and training for health workers in supporting smokers who want to stop.
Plans to reduce smoking rates also recognise the importance of key workers in public health, including doctors and GPs. However, as one of the most important points of contact for patients, nurses play a vital role in primary interventions with smokers.
Measures and interventions
The 1998 government white paper Smoking Kills sets out a range of measures aimed at preventing people from starting to smoke and helping them to stop if they do (Department of Health, 1998). At a national level, tobacco advertising was banned, packet warnings increased in size and action on tobacco smuggling intensified.
Importantly, the government has prioritised treatment for smokers. Through the NHS it set up what is now a world-leading smoking cessation service, and it has made pharmaceutical therapies for managing nicotine addiction more widely available. The following smoking cessation aids are the ones that are endorsed by clear clinical evidence and are widely available on the NHS.
Smoking cessation services
The smoking cessation services provide locally focused support for smokers who want to stop, and have helped more than 200,000 smokers do so between April 2003 and March 2004 (DoH, 2004a). Fully trained smoking cessation advisers offer group and individual support depending on the local situation and client preferences.
Most advisers are nurses or pharmacists and all have received training for their role. Services are now running in most primary care trusts offering cessation support to smokers who contact them directly and those who are referred. Many services also run clinics in GP surgeries, hospitals and in the community.
Nicotine replacement therapy
Nicotine replacement therapy (NRT) comes in several forms including patches, gum, lozenges, nicotine sublingual tablets, nasal spays and inhalators. It is designed to give patients a controlled dose of nicotine to help them manage cravings when they stop smoking.
Clinical trials have demonstrated that NRT can double the chance of a successful quit attempt, and this is even higher when supported with advice from a health professional. NRT is available through prescription and many primary care trusts have patient group directions allowing nurses to administer these therapies.
Bupropion is a drug that changes the brain’s response to nicotine, making smoking less pleasurable and reducing nicotine cravings. Bupropion has received some bad publicity linking it to seizures, although the chances of experiencing this side-effect are one in 10,000. The drug has been shown to double the chances of quitting successfully.
Role of nurses in smoking cessation
Nurses have a key role to play in influencing the health of patients. Whether working in a hospital or the community, nurses are ideally placed to encourage smokers to give up. Even the most basic intervention by a health professional can have a profound effect on encouraging a smoker to stop or to seek help in stopping.
In primary care, smoking cessation guidelines for health professionals recommend that nurses should be prepared to offer encouragement and support for known smokers to stop. Where possible nurses should be given sufficient practical and theoretical training to enable them to provide opportunistic advice, encourage cessation and offer advice on using NRT or bupropion.
Even when the smoking status of a patient is not known, nurses are in a position to record this fact and to offer brief advice. A simple piece of advice from a health professional can be a big trigger for a quit attempt.
In secondary care settings it is highly recommended that nurses should be part of systems that record the smoking status of outpatients and inpatients to ensure that these records are kept up to date. This will allow for suitable advice to be offered to patients. Many hospitals host local smoking cessation services and these should be made available to inpatients, or advisers should offer cessation counselling to inpatients.
Many smokers stop as a result of a health problem and this places nurses in the ideal position to encourage and support them to stop. Many nurses smoke themselves and may feel uncomfortable or hypocritical talking about smoking with a patient. However, it is vital to see smoking cessation information as professional advice and to treat the subject non-judgementally. Nurses will be familiar with patients’ past experiences and are well placed to be able to advise on the NHS smoking cessation services and treatments available.
Tobacco dependence is a condition that requires the same professional approach as any other. A good approach is the ‘4As’ recommended by the RCN (2001):
- Ask patients about smoking status and assess their motivation to stop;
- Advise patients on the benefits of stopping;
- Assist patients in stopping by helping them to plan and prepare for cessation;
- Arrange for them to use professional help and advice from the smoking cessation service. A detailed guide for nurses is available in Clearing the Air 2 from the RCN.
Developments and implications
The Choosing Health white paper (DoH, 2004b) continues to place emphasis on helping smokers to stop and increasing the role of the NHS in helping them do so. Perhaps the most important step has been the move towards smoke-free public places. This will include restaurants and many bars and pubs. But significantly, the NHS is committed to be smoke free by 2006. This will mean all NHS premises banning smoking throughout.
The immediate implication for nurses is that they will not be able to smoke on NHS sites. Provision will be made for nurses who want to stop. Nurses will also have an increased role in helping patients who will not be able to smoke on NHS property. The opportunity for offering help and advice will be increased as patients are reminded of smoking policies.
A smoke-free NHS and the proposal for more linked and coordinated efforts to help patients stop smoking are likely to increase the importance of nurses in smoking cessation. The role of primary care nurses will grow in importance as they are most likely to be recording the smoking status of patients and offering brief interventions. With more primary care trusts developing patient group directions and increasing the availability of NRT, this role will become even more important and influential for patients.
- This article has been double-blind peer-reviewed.
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