Nicotine addiction: clinical review

Jennifer Percival outlines the key elements of smoking cessation and how these can be applied in primary care.

Section 1: Epidemiology and aetiology
Section 2: Ask, advise, act
Section 3: Management
Section 4: Case scenario
Section 5: Evidence base


Section 1: Epidemiology and aetiology

Every year in the UK, about 96,000 people die from diseases caused by smoking. Tobacco use remains the leading cause of preventable death and disease in England and is one of the most significant factors contributing to ill health, particularly cancer, CHD and respiratory disease and health inequalities.

Although smoking in the general population has declined, 19% of adults still smoke, 20% of men and 17% of women. This means there are still 9.6m people using tobacco in Great Britain. Prevalence is highest in the 25-34 years age group (24%) and lowest among those aged 60 and over (11%).1 One in two lifelong smokers die prematurely and treating smoking-related illness is estimated to cost the NHS £2bn a year.2

Premature death is not the only problem. Smoking contributes to and complicates many other medical conditions, especially in people with long-term disease.3

Despite many smokers expressing a desire to quit, the fundamental reason for their return to smoking is their overwhelming addiction to nicotine.

Nicotine addiction

Nicotine addiction is more powerful than addiction to heroin and is classified as a chronic relapsing dependence syndrome, reinforced by sensory, behavioural and social conditioning and entrenched by a powerful withdrawal syndrome.3 This is why smokers need specialist support to break the habit.

The NHS set up Stop Smoking services to help people quit because the unaided success rate is less than 5%.4 Most GP practices have staff who are trained to provide the NHS Stop Smoking service. Nationally, these services have been highly cost-effective, saving lives and reducing health inequalities.5

Most smokers see their GP at least once a year, so it is important that primary care staff continue to give clear guidance that using an NHS Stop Smoking provider is the best way to end their addiction.


Section 2: Ask, advise, act

Groups that have the highest smoking prevalence include routine and manual workers, people with mental health disorders (including alcohol and substance use), prisoners, LGBT communities, the homeless and certain black and minority ethnic groups.

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Patients from these groups often need more intensive support and a referral to your practice specialist or NHS Stop Smoking service.4

Findings from the Smoking Toolkit Study, a continuing series of monthly surveys of a sample of the population of England aged 16+, show that more than two-thirds of smokers report wanting to stop, with 35% of these intending to make the attempt soon.6

Trying to quit

There are a number of methods that smokers commonly use when attempting to stop smoking, including trying it alone (cold turkey), buying OTC NRT, or using a stop smoking medication provided on prescription.

However, the most effective method, using an NHS trained specialist or stop smoking service, is only accessed by 5% of those people wanting to stop smoking.6

Regardless of any expressed desire to stop, all smokers attending the surgery need to be informed that the best way to quit is through a combination of behavioural support and medication from a specialist adviser, and that a referral can be made immediately.

To assist healthcare staff in delivering this message, the National Centre for Smoking Cessation and Training (NCSCT) has put together a Very Brief Advice (VBA) model which satisfies QOF criteria and can be used in almost any consultation with a smoker. An online video showing how to use this module can be viewed on the NCSCT website.7 The three elements are:

  • ASK: Establish and record smoking status
  • ADVISE: The best ways to stop
  • ACT: Offer a referral to help them quit

Section 3: Management

The most effective treatment for nicotine addiction is a combination of one-to-one psychological support by a trained specialist, and a pharmacotherapy product.

Brief advice backed up by a prescription and referral for specialist support also greatly increases smokers’ ability to quit.8

Evidence has shown that a combination of behavioural support from a trained stop smoking practitioner, with licensed pharmacotherapy, can significantly increase smokers’ chances of stopping. NICE guidance identifies an abrupt approach to stopping smoking (or quitting in one step) as the most effective method for a person wishing to give up tobacco.8

Current treatments

The stop smoking medicines currently licensed are NRT, bupropion (Zyban) and varenicline (Champix). Varenicline and combination NRT offer smokers the best chances of quitting and should be available as first-line treatments to all patients, unless clinically contraindicated.4

NRT is safe and effective. When provided by a healthcare professional and used without behavioural support, it approximately doubles the chances of long-term abstinence. There are eight types of NRT: patch (24- and 16-hour), gum, lozenge or mini-lozenge, microtab, nasal spray, mouth spray, oral strip and inhalator.

Using a combination of NRT products has been shown to have an advantage over taking one product alone, increasing the chances of quitting by up to 35%.

It is recommended that a patch is used to help with background urges to smoke, combined with a faster-acting product, such as the mouth spray or the lozenge, to top up the dose of nicotine and assist with breakthrough urges to smoke.9

Changes in therapy

The licensing for varenicline has recently changed. A large-scale trial demonstrated that use of varenicline or bupropion, in patients with or without a history of psychiatric disorder, was not associated with a significantly increased risk of serious neuropsychiatric adverse events compared with placebo. As a result, the black triangle symbol has been removed from varenicline.10

Evidenced-based support

The NCSCT has identified the competences required to deliver a smoking cessation programme and provides training and certification. The key elements are listed in box 1.

Box 1 Key elements of smoking cessation
  • Build rapport and boost motivation
  • Assess and confirm current readiness and ability to quit
  • Inform patients about the treatment programme
  • Assess current smoking behaviour and past quit attempts
  • Explain how tobacco dependence develops and assess their level of nicotine dependence
  • Measure carbon monoxide levels
  • Explain the importance of abrupt cessation and ‘not a puff’ rule
  • Discuss withdrawal symptoms, cravings and urges, and how to deal with them
  • Discuss stop smoking medications, confirming choice, correct use and supply
  • Discuss the patient’s smoking contacts and ways to get support
  • Set a quit date
  • Discuss any potential high-risk situations in the coming week
  • Advise on changing routine
  • Prompt commitment from clients (confirm the importance of the ‘not a puff’ rule)
  • Discuss future preparations and plans
  • Relapse prevention
  • Provide a summary to the patient

If a smoker wants help, but is unwilling to be referred, the main points to cover are:

  • Review past experiences of quitting. What helped and what hindered?
  • If possible, record their carbon monoxide level
  • Ask them to set a stop date and confirm the importance of stopping completely
  • Discuss nicotine withdrawal symptoms and cravings, and offer medication to reduce these, and suitable treatment
  • Discuss their expectations of the medication and provide an initial supply
  • Ask about their support network and address any potential high-risk situations
  • Make an appointment to see them the following week

Electronic cigarettes

Over the past 10 years, a range of unlicensed, nicotine containing products have become available. Originally known as e-cigarettes or e-cigs, these devices are becoming more sophisticated and are now known as vapourisers or tanks.

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Vaping is considered 95% safer than smoking, according to PHE

The term e-cig is misleading, because unlike cigarettes, the devices contain no carbon monoxide, tar or known carcinogens.

The device heats a liquid, mainly propylene glycol or glycerol, usually mixed with nicotine and flavourings, and vapour is exhaled as a visible mist by the user.

Users titrate nicotine into their bloodstream in a way similar to that provided by oral NRT products. With experience, they can adjust the level of nicotine they receive and manage their cravings. They are known as vapers because they exhale vapour, not smoke.

An independent review by Public Health England (PHE) concluded that these devices are significantly less harmful than tobacco and have the potential to help smokers quit.11

While vaping may not be 100% safe, most of the chemicals causing smoking-related disease are absent and those which are present pose limited danger. PHE also found no evidence that the devices act as a route into smoking for children or non-smokers.

The review noted that although there had been a shift towards the inaccurate perception that vaping is as harmful as cigarettes, current expert opinion is that it is about 95% safer than smoking.

Although these products are unlicensed and cannot be prescribed, they represent a safer alternative to cigarettes for smokers who are unable or unwilling to quit.

A Cochrane review concluded that vaping devices can help people to quit smoking and may be contributing to the decline in smoking.12 It also found some evidence to suggest that use of the devices can lead to abstinence in some smokers who had not intended to quit.

The NCSCT recommends that practitioners should be open to vaping in smokers trying to quit, particularly if they have tried other methods and failed. It has issued guidance for healthcare staff on ways to support people choosing to quit using their own vaping device, with or without NRT.13 Vaping by pregnant women has also been considered and the conclusion is that while licensed NRT products are the recommended option, if a pregnant woman chooses to use a vaping device to help her stay smoke-free, she should not be discouraged from doing so.14

The greatest public health gain will be achieved by encouraging greater numbers of smokers to try to give up smoking more often, to use a treatment product and to seek support from a specialist stop smoking adviser.


Section 4: Case scenario

A 54-year-old patient who has recently completed a cardiac rehab course following an MI attends the surgery. When you ask him about his smoking, he replies: ‘I’ve cut down on how much I smoke since I had my heart attack.’ What is your next step?

Reflecting on choices

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Cutting down can be more difficult than quitting for some patients

Although it is tempting to provide facts on the risks and recommend quitting smoking, this patient needs help to reflect on the consequences of his choice.

Try asking him: ‘What made you decide to cut down and not stop completely?’

Clarify the facts by asking: ‘How much were you smoking before and how much are you smoking now?’

Explain that cutting down on smoking can be more difficult than stopping for some people – and ask about his experience.

For example, smokers who ‘cut down’ often continue to receive the same amount of nicotine, by taking deeper and more frequent puffs.

Then ask: ‘Are there some days when you smoke more than you intended to?’ The answer is likely to be yes. Now explore what he understands about the impact of smoking on his condition. Ask him: ‘What do you think could happen if you don’t stop completely?’ Then say you can help and offer a prescription for the cravings and refer him to a specialist service.


Section 5: Evidence base

Online resources

The NCSCT provides a comprehensive smoking cessation training and assessment programme. It has also developed a complete list of behavioural support competences, available as learning outcomes in the NCSCT Training Standard.

Also available is Electronic cigarettes: A briefing for stop smoking services, which makes recommendations for stop smoking practitioners and services, provides FAQs about the devices and summarises evidence on which its recommendations are based.

  • Jennifer Percival, counsellor and national trainer in smoking cessation and behaviour change

Take a test on this article and claim your certificate on MIMS Learning

References

  1. Action on Smoking & Health. Smoking Statistics
  2. Action on Smoking & Health. Tobacco Economics
  3. Royal College of Physicians. Nicotine addiction in Britain: a report of the Tobacco Advisory Group of the RCP. London, RCP, 2000
  4. NCSCT/Public Health England. Local Stop Smoking Services. Service and Delivery Guidance 2014.
  5. Bauld L, Judge K, Platt S. Tob Control 2007; 16: 400-4
  6. Smoking Toolkit Study
  7. NCSCT. Very Brief Advice training module
  8. NICE. Stop smoking services. PH10
  9. Stead LF, Perera R, Bullen C et al. Cochrane Database Syst Rev 2012 Nov 14; 11: CD000146
  10. Anthenelli RM, Benowitz NL, West R et al. Lancet 2016; 387: 2507-20
  11. Public Health England. E-cigarettes: an evidence update. A report commissioned by Public Health England
  12. McRobbie H, Bullen C, Hartmann-Boyce J et al. Cochrane Database Syst Rev 2014; 12: Cd010216
  13. NCSCT. Electronic cigarettes: A briefing for stop smoking services
  14. NCSCT. Smoking Cessation: A briefing for midwifery staff

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