The UK is admired internationally for its determination to tackle smoking; in 2019, only around 14% of adults in the UK smoked (Office for National Statistics, 2019; Action on Smoking and Health (ASH), 2021), and more can be done to accelerate this trend, to support the national ambition for a Smokefree 2030 (Smokefree Action Coalition, 2022). The fall in smoking rates has been achieved with a comprehensive range of tobacco control measures, including smokefree legislation, raising the age of sale for tobacco, banning cigarette displays and plain packaging. The UK's approach to the use of e-cigarettes (vapes) has also played a part. In September 2022, the Office for Health Improvement and Disparities (OHID, 2022a) published the last in their series of evidence updates on nicotine vaping. This extensive report gives assurance on comparative safety when measured against smoking, and recommends that health professionals do all they can to encourage patients who smoke to switch to vaping (OHID, 2022a).
Smoking rates have fallen dramatically since the early days of Stop Smoking Services (SSSs). In 1999, when the first SSSs were launched, people queued to get support to quit. However, in 2022 a very different picture emerges; particularly in disadvantaged areas of the country, where people who still smoke are less interested in quitting and not at all confident that they could manage it even if they tried. Smoking continues to harm the health of people who live in difficult circumstances (OHID, 2022b).
The insights work conducted by Bluegrass Research on behalf of ASH (2022a) gives us a rich and detailed understanding of what people who need to stop smoking think and believe. The resistance of patients who smoke can be disheartening for health professionals, who may feel that it is not a good use of their time to raise the subject of smoking.
‘I don't care. I'm happy to be a smoker. It's my only outlet. I don't go out. I don't do anything else. I'm quite happy to be a smoker.’ Bluegrass/Social housing, Northern coastal town. Aged 35-44
These insights can be used to get better results. We know that stopping smoking is the single best thing anyone can do for their health. Smoking not only kills people prematurely (ASH, 2021), it can also keep smokers in poverty and increases the number of years they live with poor health and disability. General practice nurses can make a significant contribution to addressing this, by using insights into the smoker's mindset, and asking the right questions, painting a picture that will engage rather than shut down the conversation. This can be done without adding extra precious time to a face-to-face consultation.
‘A positive message about the benefits of quitting rather than the harms can act as non-confrontational encouragement.’
Lack of confidence
The Bluegrass study reveals the challenging lives of people who smoke (ASH, 2022a). Often juggling childcare, low-paid work, debt, their own and other family members’ poor physical and mental health, they describe going out for a cigarette as the only bit of ‘me time’ they get. This can make people feel that stopping smoking removes their one single reliable pleasure, and strengthens their doubt that they could manage going smokefree even if they wanted to. General practice nurses may feel that it is not worth even asking; they are all too familiar with patients’ difficult lives.
‘It's just my mental health at the moment. It's a lonely place to be and when you get lonely it gets stressful for you and when you get stressed you just have a fag. I'm on my own, that's why I smoke really.’ Bluegrass/Blackpool. Aged 18-24
The stigma of asking for help
People who smoke often think that asking for help is a sign of weakness.
‘I don't think I need to talk to anyone else…no one else can stop smoking for me.’ Bluegrass/living below the poverty line, male, North/Mids
Stop-smoking practitioners have a wealth of experience, and many strategies at their fingertips, to help even the most resistant smoker to get on their smokefree journey. This expertise is offered free of charge. The challenging part is how to get these patients quit-ready.
A worthwhile intervention
It is worth explaining how rapidly the health benefits of stopping smoking accrue: of all the health changes a patient can make, this is one of the most effective. The timeline for health improvements is detailed on the NHS Better Health website (NHS Better Health, 2022).
Very brief advice
The Bluegrass study (ASH, 2022a) asked people who smoke about what advice they were given. People talk about feeling pressurised by healthcare staff into stopping smoking, or that their nurse or doctor blame everything on smoking, ‘even a stubbed toe’.
The remedy for this is to refine the way the conversation goes. The one question not to ask is if they are interested in stopping smoking; this automatically makes people defensive.
The National Centre for Smoking Cessation and Training (NCSCT, 2022) has a free e-learning module to build the skills needed to deliver very brief advice effectively. The ‘Ask Advise Act’ method identifies that the patient smokes (‘Tell me, are you still smoking at all?’). This is followed up, not with a question about whether they are interested in quitting, but with a motivational statement: ‘Did you know that the very best thing you can do for your health is to stop smoking, using a combination of support and a stop-smoking aid?’
While they are reflecting on what has just been said, the practice nurse can take advantage of the moment by signposting, or referring, to a service that can help, for example an in-house SSS, or the service commissioned by the Local Authority, or digital support from an app. This can remove a significant barrier: the patient doesn't have to search for options, because the general practice nurse has provided exactly what they need to know.
Rather than make the patient feel that the health professional blames smoking for any or all of their health problems, a positive message about the benefits of quitting rather than the harms can act as non-confrontational encouragement. For example, mentioning that their leg ulcer is much more likely to heal well if more oxygen is getting to the wound may have more impact than confirming their unspoken fears: that their smoking is making their condition worse. Tailoring the message to their presenting condition - diabetes, asthma, respiratory illness, for example - makes the intervention more powerful.
Demystifying the stop-smoking pathway
People who are even casually entertaining the idea of getting support to stop smoking need to know what to expect. The fear of being judged, blamed, lectured or patronised creates an obstacle that can be hard to overcome.
‘I feel like they probably would have things to say, but it's just don't have a fag, at the end of it. So I'd like just go in like cold turkey and just try and do it myself’. Bluegrass/NEET, Mids/Northeast
General practice nurses can give reassurance that SSS users really appreciate the support they receive. Even more importantly - and this needs emphasis - SSSs do not do groups anymore. General practice nurses can assure patients that they will be seen at weekly one-to-one appointments, by an advisor who understands what they are going through. They will get evidence-based strategies to manage life without cigarettes, and products to make the process much more comfortable.
Tackling the fear of nicotine
The health world has done such a good job of warning people about nicotine that they are now more scared of that than they are of the smoke. It is the smoke in a lit cigarette that kills (OHID, 2022b) - nicotine is what makes it enjoyable, and clean nicotine without smoke is the very thing that gives people a literal breathing-space while they adjust to not smoking. People say they are afraid of ‘getting addicted to something else’. Nicotine replacement contains the same nicotine that they were getting when they were smoking, but in a clean form. It helps to think of it as an anaesthetic for stopping smoking; nicotine replacement therapy (NRT) products or a vape can make the transition from smoker to smokefree so much easier and less painful. There is no intrinsic virtue in doing it the hard way. The NHS website provides a useful summary of all stop-smoking aids (NHS, 2022).
Be open to vaping
E-cigarettes (EC), commonly referred to as vapes, are now the most popular and most effective method for stopping smoking (OHID, 2022a), and are listed along with combination NRT and varenicline (National Institute for Health and Care Excellence, 2021) as the treatment for smoking with the strongest evidence. Referring to an EC as a vape changes the incorrect assumption that smoked cigarettes and electronic cigarettes are equally harmful (Newton, 2020). Some people talk about ‘smoking an e-cigarette’, which is both inaccurate and misleading. These devices deliver clean nicotine without the harmful smoke that comes from a combustible cigarette. They work in a similar way to NRT, and are more pleasant to use, without the side-effects that patients often complain about with patches, gum and other NRT products. It is the tar and carbon monoxide that cause the many smoking-related illnesses; the nicotine is one of the least harmful chemicals (Royal College of Physicians, 2021).
A randomised controlled trial (Hajek et al, 2019) demonstrated that using a vape to stop smoking was twice as successful as using NRT, and the Cochrane Systematic Review corroborates this (Hartmann-Boyce et al, 2020).
‘This is the only time I have been able to stop. I used to think I have my last cig I'm going to stop, and I would only go 2 or 3 days and buy some, but now I have my vape it never enters my head.’ Bluegrass/Quitter who vapes
Vapes have been used for over 15 years in the UK, with very few adverse events. They are included in the Medicines and Health Products Regulatory Agency (MHRA) Yellow Card system. Patients who vape to stop smoking should be advised to drink plenty of water to counteract the drying effect the vapour can have on the mouth and throat.
There are still many misconceptions among both the general public and health professionals about vaping, and the ASH (2022b) report on the use of EC emphasises how detrimental this is to public health. The Royal College of Physicians (2021) report recommends that EC are included in standard protocols to treat tobacco dependency. The Royal College of Nursing (2022) website states that while not risk-free, EC carry a fraction of the risk of smoking cigarettes. If a person is smoking tobacco, they have at least a 50% chance of dying from a smoking-related disease, often in middle age. General practice nurses can do much to raise awareness of this evidence-based means of stopping smoking, not just among patients but also with colleagues who may still hold outdated ideas about the potential of vaping to tackle tobacco dependence. The Cochrane review on EC (Hartmann-Boyce et al, 2020) provides compelling information that will fill in knowledge gaps on the subject. General practice nurses will also find the NCSCT briefing (2016) on e-cigarettes informative.
Digital support may be easier
Face-to-face support, using a combination of behavioural support and a stop-smoking aid (nicotine replacement or a vape), is proven to be the most effective way to stop smoking (NICE, 2021). However, some local authorities have stopped funding a local SSS and, since the start of the COVID-19 pandemic, many services have replaced their face-to-face treatment with telephone support. This has opened up the possibility of using digital support to stop smoking, via an app. Convenient, easy to access and offering relative anonymity, stop smoking apps offer support at any time of the day or night, and can complement what is offered by traditional services, or provide a solution for people in areas where no SSS exists. The independently-published Organisation for the Review of Health and Care Applications (2021) report describes the benefits apps can offer to people who smoke.
Conclusion
During the COVID-19 pandemic, many health priorities were downgraded while the new challenges were tackled. Smoking-related illnesses though, particularly cancers, respiratory and cardiovascular disease, have not gone away; smoking accounts for around 74 600 deaths in England every year (ASH, 2021). This particularly affects the most disadvantaged families in our society (Payne et al, 2022). General practice nurses have many opportunities to start a conversation with patients about their smoking; every interaction can be turned into a teachable moment for patients who may be in denial that smoking has caused, or is worsening, their condition.
General practice nurses have the skills and the knowledge to make a difference for patients who smoke. A good intervention, that understands patients’ low confidence levels, their fears about what will happen if they do accept support, and how to choose a way of quitting that is more likely to be successful, will contribute to more successful quitters, less disabling disease and early death, and a brighter future for the patient's whole family.
CPD REFLECTIVE PRACTICE:
- How could you implement very brief advice for smoking cessation into your routine consultations?
- Are you confident describing your local stop smoking pathway to patients? Where could you get more information on this?
- How would you explain the place of ‘vapes’ in smoking cessation? How could you tackle misconceptions from patients?
KEY POINTS:
- Helping people stop smoking remains a key health priority
- General practice nurses should raise the subject during appointments with patients who smoke
- All contacts with patients who smoke can be turned into teachable moments
- Insights into patients’ mindsets can help practice nurses fine-tune their approach
RESOURCES:
- National Centre for Smoking Cessation and Training. Very brief advice. https://www.ncsct.co.uk/pub_training.php
- National Centre for Smoking Cessation and Training. Electronic cigarettes: a briefing for stop smoking services. http://www.ncsct.co.uk/usr/pub/Electronic_cigarettes._A_briefing_for_stop_smoking_services.pdf
- NHS. Stop smoking treatments. https://www.nhs.uk/conditions/stop-smoking-treatments/