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Preparing for smoking cessation ahead of the ban

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VOL: 103, ISSUE: 02, PAGE NO: 23

Emma Wilkinson, MA, BSc, is acting assistant clinical editor, Nursing Times

The government has announced the smoking ban in England will come into force on 1 July 2007. Bans are set to start in Wales and Northern Ireland from April 2007, while Scotland has had a ban since March 2006. In addition the government announced last week that the legal minimum age to buy tobacco is to rise from 16 to 18 in England and Wales in October.

The government has announced the smoking ban in England will come into force on 1 July 2007. Bans are set to start in Wales and Northern Ireland from April 2007, while Scotland has had a ban since March 2006. In addition the government announced last week that the legal minimum age to buy tobacco is to rise from 16 to 18 in England and Wales in October.

The commitment to ban smoking was outlined in the Choosing Health white paper (Department of Health, 2004). The subsequent Health Bill proposed to ban smoking in all enclosed public places, apart from licensed premises that do not serve or prepare food and private members' clubs. However, some MPs thought this did not go far enough and could potentially increase health inequalities.

In a free vote in February 2006 MPs voted to ban smoking in all enclosed public places such as pubs, cinemas, offices, factories and public transport. People will be limited to smoking outside or in their own homes. As well as limiting the adverse effects of passive smoking, ministers expect about 600,000 smokers to quit because of the ban.

THE SCOTTISH EXPERIENCE
An analysis by researchers at the University of Bath found that in the three months before the smoking ban was introduced in Scotland the number of smokers wanting to quit doubled, although numbers dropped quickly once the ban was in place (Bauld, 2006).

A smoking-cessation service in Scotland treated 360 smokers from January to March 2005, compared with 690 in the three-month run up to the ban. The country's biggest service saw 7,476 clients in the run-up to the ban, compared with 5,209 in the same period of the previous year. The researchers warn that a similar pattern is likely in the rest of the UK and that smoking-cessation services and health professionals need to plan ahead to meet the demand.

Health benefits of the smoking ban in Scotland have already been reported (Menzies et al, 2006). Respiratory and sensory symptoms fell by 47% in bar workers two months after the ban. Asthmatic bar staff had less airway inflammation.

SMOKING AND DISEASE
A 1998 strategy paper looking at the cost-effectiveness of smoking-cessation services reported that smoking directly cost the NHS £1.5bn every year. Increasing the rate of people giving up smoking by just 5% would save the NHS £44m in the next 20 years (Parrott et al, 1998). In addition:

- According to NHS figures, 22% of deaths in men and 11% of deaths in women are due to smoking (www.givingupsmoking.co.uk);

- About 90% of peripheral vascular disease that leads to amputation of one or both legs - approximately 2,000 amputations a year - is caused by smoking;

- Some 83% of lung cancer deaths in England are smoking-related but there is an increased risk of other cancers including mouth, throat, bladder, kidney, pancreas, stomach and cervix;

- Smoking increases the risk of osteoporosis in women by 5-10%;

- Smoking can lead to impotence and fertility problems, as well as miscarriage, low birthweight babies and cot death;

- One in 10 deaths from stroke is linked to smoking;

- Smokers are more than twice as likely to die from coronary heart disease and 44% of such deaths in the under-65s are caused by smoking;

- More than 80% of deaths from emphysema and bronchitis are due to smoking.

NHS STOP SMOKING SERVICES
NHS Stop Smoking Services have been in place since 1999 to offer behavioural support (one-to-one and group) and access to smoking-cessation therapies such as nicotine replacement therapy (NRT). Supported quit plans are about four times as successful as willpower alone. Local services can be accessed through the national website (www.givingupsmoking.co.uk) or through a national helpline on 0800 169 0169 or even by texting a postcode along with GIVE UP to 88088. Smokers who want to quit can also be referred to NHS Stop Smoking Services by their GP or other health professional.

Nurse practitioners play a major role in NHS Stop Smoking Services. A Cochrane review reported that patients who received advice from a nurse were more likely to quit than those receiving usual care either in hospital or outpatient clinics (Rice and Stead, 1999), supporting the use of smoking-cessation counselling from nurses.

A Scottish study of nurse provision of opportunistic brief health education about smoking for patients in hospital found that most nurses recognised opportunities to educate patients about the dangers during care. It concluded that when patients are in hospitals for short periods of time, opportunistic health education from nurses should be routine (Whyte et al, 2006).

NICE is set to produce draft guidance in November 2007 on the optimal provision of smoking-cessation services with particular reference to manual groups, pregnant smokers and hard-to-reach communities.

THERAPIES
In 2005 NICE updated its guidance on smoking-cessation therapies - NRT and bupropion (NICE, 2005).

NRT and bupropion (an antidepressant that was found to help people quit smoking) are available on prescription for smokers wishing to quit. They should normally be prescribed once smokers commit to a quit date and should be accompanied by advice and encouragement. The first prescription of NRT or bupropion should only last until two weeks after the target stop date, which means a three-week prescription, as it should be initiated one week before the target stop date.

Although NRT is also available without prescription, it is recommended that under-18s, pregnant or breastfeeding women, or anyone who has an unstable heart condition should talk to a nurse or doctor before starting treatment. Likewise, bupropion is not licensed for use in smokers aged under 18, and should not be used in women who are pregnant or breastfeeding.

In December 2006 varenicline (Champix) - the first non-nicotine drug specifically designed to help smokers quit - became available in the UK. It works by mimicking the effect of nicotine on the body. By partially blocking nicotinic receptors in the central nervous system, varenicline can relieve withdrawal symptoms and make the effect of smoking less pleasurable should the smoker give in to temptation. There is likely to be substantial demand for the drug, which costs about £1.95 per day. However, local policies on the prescribing of the drug may differ.

NICE is due to consider evidence on the drug in April 2007. In the meantime, guidelines for health professionals have been published by Action on Smoking and Health (ASH, 2006).

Varenicline is licensed for use by all smokers except those with severe renal impairment, those who are pregnant or breastfeeding, and those under 18. The only side-effect seems to be nausea but as with all newly licensed drugs patients should be encouraged to report any problems. As with bupropion, treatment begins a week before the quit date and it should only be used in conjunction with support from a smoking-cessation service. The dose is titrated up to 1mg twice daily for 12 weeks, at which point a further 12-week course can be considered.

About 44% of smokers who took part in trials were able to quit after using the drug for 12 weeks.

SELECTING AN APPROPRIATE THERAPY
The following factors should be taken into account:

- Whether the person has used treatments in an attempt to stop smoking in the past

- Medical contraindications to smoking-cessation treatments

- Which treatment the patient prefers

- Intention and motivation to quit

- Availability of counselling and support

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