Smoking cessation: what really works?
Ann Cook offers tips for helping patients to quit
For some time now our practice has been recording smoking status on most patients attending for routine diabetes, asthma, CHD and cervical smears. As a rule, no one is prescribed nicotine replacement therapy (NRT) unless they are prepared to see the smoking cessation counsellor. This allows adequate monitoring and support and ensures NRT is only prescribed where appropriate.
With the new contract we target smokers more specifically. All CHD patients identified as smokers are sent a leaflet on the benefits of not smoking and listing expected side-effects during a quit attempt. At CHD appointments their motivation is assessed and, if appropriate, they are offered an appointment with the smoking cessation counsellor.
A patient's motivation can be assessed as part of a 10-minute consultation. For example, the Smoking Cessation Action in Primary Care 30-second approach recommends a series of simple closed questions (www.Click2Quit.com).
Smokers who want to quit are then seen weekly for four to five weeks. The initial interview lasts 20-30 minutes and looks at smoking history, reasons for wanting to stop, previous attempts and why they failed. People smoke for different reasons boredom, stress relief, 'time out', 'me time' and it is important to stress the need to deal with these issues to enable a successful quit attempt. Relaxation exercises, yoga, exercise and new hobbies may help.
Patients need to choose the NRT method that is most appropriate for them. NRT doubles the success rate of quit attempts. Many say they have tried NRT in previous attempts but without success. Often they have not used enough: in the first two weeks they must keep levels up to deal with withdrawal symptoms. Oral dosing allows the individual to regulate the amount of nicotine they need. Patients must expect to suck/chew lozenges or gum almost constantly in the first few weeks.
Some smokers prefer the patch, especially at work, as it is a more discreet method. But there may be certain times of the day when the patch delivers insufficient nicotine to cope with the cravings.
In this case an oral therapy microtabs or an inhalator can be used to top up the dose. Patients must expect to fund such additional methods themselves.
At the initial interview patients receive a leaflet explaining this and addressing safety concerns. They also receive handouts on withdrawal symptoms and the benefits they may expect to experience over coming weeks by stopping smoking. Withdrawal symptoms that patients should be warned of are listed overleaf.
If necessary, follow-up appointments after the first four to five weeks deal with any problems with NRT and withdrawal symptoms, and offer support generally and monitoring of carbon monoxide (CO) levels and relapse prevention.
Carbon monoxide levels are monitored weekly with a 'Smokerlyzer' which measures parts per million CO in the blood stream. Smokers can have 2-20 per cent of their normal blood oxygen replaced by CO, so the heart beats faster and there is risk of damage. Monitoring the fall in CO levels encourages the quitter by demonstrating they are returning to normal as a result of abstinence. 'Smokerlyzers' may be supplied by your local health promotion department, together with mouthpieces and a calibration service.
When bupropion (Zyban) became popular here four years ago our practice started using it for heavy smokers who had been unsuccessful in previous quit attempts, especially if these had involved NRT. But we found significant side-effects, including depression, dizziness and severe headaches. Success rates did not appear to be any better than NRT.
This and reports from the manufacturer of adverse health effects have meant the GPs in the practice now use NRT as firstline treatment. With behavioural support from the smoking cessation counsellor, NRT gives success rates of 40-60 per cent.
Smoking cessation counsellors play an important role in primary care, offering behavioural support and specialist advice that GPs often don't have time to give. But they require extensive training and regular updates. They don't have to be a practice nurse: they could be a PCT member, health visitor or district nurse.
Ann Cook is a practice nurse and smoking cessation counsellor in East Grinstead, Sussex
Common issues for smokers trying to quit
trying to quit
'I don't like the taste of microtabs/gum/lozenges'
They may taste strange at first but patients should think of them as medicines that are making them better; if they persevere they will get used to the taste. There are different flavours of gum and lozenges.
'Will I get hooked on NRT?'
The main problem is NRT under-use not over-use. NRT will not create a new dependence as patients are already hooked on nicotine, but they will obtain a lower dose than when they smoked and without the dangerous chemicals. They may like NRT and come to rely on it, but this is part of the treatment. The great majority stop NRT well within the recommended duration.
It is important to explain that NRT is not a
magic cure and will not entirely remove the urge to smoke. Patients' effort and determination are still essential.
'Will I put on weight?'
The patient may eat more to compensate for not smoking but not everyone puts on weight. NRT can act as an appetite suppressant. Patients will find they have more energy once they have stopped smoking; they should be encouraged to take this opportunity to increase their exercise. Local leisure centres may offer exercise scheme at a reduced cost on recommendation of a GP. Ask your local health promotion department for the useful leaflet Quit Smoking Without Putting on Weight.
'I'm not sleeping very well'
This is a normal side-effect of withdrawal, though less common with the 16-hour patch than with the 24-hour patch. It is temporary and usually improves within a few weeks.
·The new online service www.Click2Quit.com supports patients in their quit attempts it has a useful section for health professionals which includes a downloadable patient leaflet
·www.givingupsmoking.co.uk gives professional and patient advice, such as where to find the nearest NHS smoking cessation service
·www.doh.gov.uk/tobacco/cessation.htm provides links to smoking cessation guidelines and initiatives
·Molyneux A. Nictoine replacement therapy.
·Hajek P. Effective use of nicotine replacement therapy. Prescriber 1998;21:22-4
·NICE guidance on the use of nicotine replacement
therapy and bupropion for smoking cessation.
Technology Appraisal Guidance No 39. Available at www.nice.org
·NHS Smoking Helpline: 0800 169 0169
·Quitline: 0800 00 22 00
·NHS Pregnancy Helpline: 0800 169 9169