The UK has pioneered a world-class approach to tackling smoking, and in 2019, only 14.1% of adults in the UK smoked cigarettes (Office for National Statistics, 2020). The smoking rate is 6% lower than in 2011, and rates have fallen dramatically since the early days of Stop Smoking Services (SSSs); however, those patients who still smoke continue to present a challenge, clustered as they are in poorer communities and among people with poor mental health (ONS, 2020; Public Health England, 2020a; Action on Smoking and Health (ASH), 2021a).
In 2018/19, over 500 000 NHS hospital admissions in England were attributed to smoking (Public Health England, 2020b; NHS Digital, 2020).
A new All-Party Parliamentary Group (APPG) on Smoking and Health report (2021) outlines achievable goals to reach the milestone of a Smokefree 2030 (British Heart Foundation, 2021). The report emphasises that stopping smoking is the single best thing anyone who smokes can do for their health. Smoking not only kills people prematurely, it can also keep them in poverty and increases the number of years people live with poor health and disability. Areas of the country with the highest deprivation scores are where people smoke the most (APPG, 2021).
To achieve the national ambition of a Smokefree 2030, new strategies are needed, and practice nurses are part of the way forward. New and refreshed approaches are key to addressing the issue, and five approaches that practice nurses can adopt, without the need for additional resources, are discussed here:
- Very brief advice
- Digital support
- Positive reframing
- Vaping
- Experts by experience.
Very brief advice
Raising the subject of smoking with patients should be standard practice in all healthcare settings, but we know from a study published by Cancer Research UK (2019a) that only 53% of primary care staff frequently complete a Very Brief Advice (VBA) intervention with patients (ie, including all components: Ask, Advise and Act). The report says that primary care staff do ask about smoking, but when training staff, we hear examples of conversations that do not get to the point efficiently enough, nor in a way that motivates the patient to act on the advice given.
For example, asking how many cigarettes a patient smokes, or what brand, may take the conversation down the wrong track. Even if they admit to smoking two a day, this is still harmful and is likely to be an underestimate, playing down the patient's dependence on tobacco. Asking if the patient is interested in stopping smoking also misses an opportunity. Patients will often say no, or that they will think about it, and the moment is lost.
The National Centre for Smoking Cessation and Training (NCSCT, 2014) has a free e-learning module to build the skills needed to deliver VBA most effectively. The ‘Ask Advise Act’ method identifies that the patient smokes (‘Tell me, do you smoke at all?’). This is followed up, not with a question of whether they are interested in quitting – many people say they want to quit but do not get as far as doing something to make this happen – but with a motivational statement: ‘Did you know that the very best thing you can do for your health is to stop smoking?’ If you can tailor this to their presenting condition – diabetes, asthma, respiratory illness for example – this makes the statement even more powerful. While they are reflecting on what you have just said, you can take advantage of the moment by signposting to or referring to a service that can help, for example your in-house SSS, or the service commissioned by your local public health directorate, or digital support from an app. This can move the patient from undecided or resistant to open-minded and ready to act.
Digital support
Face-to-face support, using a combination of behavioural support and medication or nicotine replacement, is proven to be the most effective way to stop smoking, as seen in the CRUK infographic (CRUK, 2019b). However, some local authorities have stopped funding a local SSS, and since the start of the COVID-19 pandemic, face-to-face treatment has largely been replaced with telephone support. It is likely that remote support will continue to be the delivery method of choice while there is a need to reduce face-to-face contact as much as possible, and this opens up the possibilities of patients using digital support to stop smoking, via an app such as the Smoke Free app (www.smokefreeapp.com). Convenient, easy to access and with relative anonymity, stop smoking apps offer support at any time of the day or night, and can complement what is offered by traditional services. It can be useful to read the independently-published Orcha report (2021) to see what benefits apps can offer to people who smoke.
Positive reframing
Sometimes it is the feeling of hopelessness that deters patients who smoke from acting on any prompts to stop smoking. They may feel that after so many years of smoking, the damage has already been done, especially if they have smoking friends or family members who have become ill with cancer, respiratory illness or cardiac disease. A simple reframing exercise led by the practice nurse, from negative to positive, may prove effective in getting patients to change their minds. Instead of warnings about the dangers of smoking, describing the healing process, in a way that is tailored to their condition, can work wonders. People on clozapine, for example, may not know that stopping smoking means that, under supervision, their drug dose can be reduced, as described by the NCSCT (2018). A person undergoing cancer treatment will be more likely to benefit fully from the treatment if they stop smoking; the Macmillan website has clear information about this (Macmillan, 2017). A pre-surgical patient who stops smoking will improve wound-healing because of the improved oxygen supply to the surgical site, and the NCSCT has an informative factsheet about this (NCSCT, 2020). Even a casual enquiry from a practice nurse, framed as curiosity rather than what might be taken as censure, can be a teachable moment. Questions such as ‘What is it that you really enjoy about smoking?’ and ‘Do you think you'll smoke forever?’ can move patients towards a decision that could give them extra years of disease-free life.
Vaping
Still commonly referred to as e-cigarettes (EC), vapes are now the most popular and most effective method for stopping smoking, as described by the head of the Public Health England Tobacco Programme (Dockrell, 2019). Referring to an EC as a vape is helpful as it avoids the common 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, and they work in a similar way to nicotine replacement therapy (NRT), although in a more pleasant way (ASH, 2021b), without the side-effects that patients often complain about with patches, gum and other NRT products (NHS, 2019). It is the tar and carbon monoxide that causes the many smoking-related illnesses we see among smokers; the nicotine is one of the least harmful chemicals (Royal College of Physicians (RCP), 2021).
A randomised controlled trial (Hajek et al, 2019) demonstrated that using a vape to stop smoking was twice as successful as using NRT.
At the time of writing, the NICE guidance NG92 is being replaced, along with a number of other tobacco-related NICE guidance documents, by a new overarching set of guidelines. A draft of Tobacco: preventing uptake, promoting quitting and treating dependence (2021) is out for consultation and should be published towards the end of 2021. This strengthens the recommendation to include nicotine-containing ECs in the list of options for people who want to stop smoking. ECs have been used for around 10 years in the UK, with very few adverse events. They are included in the Medicines and Health Products Regulatory Agency (MHRA) Yellow Card system, but only a few adverse event reports have been submitted, mainly dry mouth and throat (ASH, 2021b). 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 is still much misinformation among both the general public and health professionals about vaping, and the ASH report (2021b) emphasises how detrimental this is to public health. The Royal College of Physicians report (2021) recommends that EC are included in standard protocols to treat tobacco dependency. The Royal College of Nursing (RCN, 2020) website states that while not risk-free, EC carry a fraction of the risk of smoking cigarettes. If a person is smoking tobacco, we know they have at least a 50% chance of dying from a smoking-related disease, often in middle age. Practice nurses can do much to raise awareness of this highly promising means of stopping smoking, not just among patients but also with colleagues who may still hold outdated ideas about the potential of EC to tackle tobacco dependence. The Cochrane review on EC (Hartmann-Boyce et al, 2021) provides compelling information that will fill in knowledge gaps on the subject. Practice nurses will also find the NCSCT briefing (2016) on ECs informative.
Experts by experience
In addition to improving knowledge by reading studies and articles, there is much to be gained by talking to people who have quit smoking. The insights that can be gathered from patients can be very illuminating, particularly among those who quit with vaping. As a service manager at the Leicester City SSS, I was regularly educated by clients who had stopped smoking, and their personal stories helped form my team's overall strategy, building confidence on what works for smoking cessation. This is particularly true of people with poor mental health, who tend to smoke much more than the general population and who have more co-morbidities (ASH, 2021a). When a person is admitted to a psychiatric unit while acutely unwell, they find that the site has a smokefree policy, and it is likely to be a challenge when they are already struggling to cope. Patients will often say that being able to use a vape on the site helped them get through a difficult time with relative ease. All personal stories contribute to knowledge of what works that a nurse can use for other patients.
Conclusion
Since the beginning of the COVID-19 pandemic, many health priorities have been downgraded because of new challenges presented by managing the virus. Smoking-related illnesses though, particularly cancers, respiratory and cardiac disease, have not gone away; smoking accounts for around 74 600 deaths in England every year, according to Action on Smoking and Health (2021a). Practice nurses have many opportunities to start a conversation with patients about their smoking; every interaction can be turned into a learning moment for patients who may be in denial that smoking had caused or is worsening their condition.
A fresh approach – Very Brief Advice delivered optimally, reframing, adding the possibility of digital support to stop smoking, hearing patients' lived experience and an open-minded approach to the use of e-cigarettes – can have the dual benefit of helping nurses feel that what they say really does make a difference, along with motivating more patients to take that big step towards a smoke free future. People who smoke generally wish they had never started, but were gripped by dependence for years, many having started as children. They typically search for something new that could help them stop, always hoping that this time it will work. Practice nurses have the power to keep that hope alive.
KEY POINTS:
- Smoking remains a key health priority
- Practice nurses can address this during appointments with patients who smoke
- All contacts with patients who smoke can be turned into teachable moments
- There are new ways to engage patients' interest
CPD reflective practice:
- Are you confident that you understand the benefits of vaping? If not, where could you get up to date evidence?
- Reflect on your practice, could you improve the way you tackle the topic of smoking with your patients?
- What are the arrangements for stop smoking services in your area? Do you know where to refer those who want to quit?
- How will this article change your practice?