It is clear smoking is associated with a number of serious health conditions including malignancy, COPD and cardiovascular disease.
This has been recognised by the Health Act 2006, which subsequently came into force in 2007.1 The Act imposed restrictions on where people may smoke. According to government sources, the prevalence of smokers fell to its lowest ever recorded level in 2007. There has been a huge effort by the NHS to reduce smoking for many years and it features highly in the quality and outcomes framework.
It is critical to ensure we, as clinicians, are aware of our patients' views on their smoking habits. Opening dialogue about smoking habits during a consultation may be uncomfortable but this should not be the case, particularly given that data suggest 66 per cent of smokers express the desire to quit.2 It is imperative we routinely ask about smoking habits.
It is easy to make the presumption that patients are pre-contemplators, that is to assume they enjoy smoking and are resistant to quitting, and consequently focus the consultation on the dangers of smoking.3
Of course, if a patient is a contemplator, meaning they are already considering quitting, a lecture on smoking will merely serve to damage the doctor- patient relationship.
Conversely, if the doctor or nurse open-endedly asks about a patient's view on their smoking habit, the patient will either volunteer their enjoyment of the habit, or their keenness to quit. Now the consultation can follow in a patient-centred way.
If patients are not ready to stop smoking, it is important to offer them help in the future if they so wish, and to review their views at least annually.
Some patients will elect to quit under their own willpower. Their strategy will depend on a number of factors including fear of withdrawal symptoms, their experience of previous attempts and concern over weight gain.
Some patients may respond to self-help material on the internet or referral to the NHS quit line. Simple advice of two to three minutes produces an increase in quit rate of around 2.5 per cent.4 However, it is clear more robust measures are required.
More intense discussion with regular follow-up can produce higher cessation rates.5 There is not sufficient evidence to advocate the use of hypnotism or acupuncture, although many patients swear by their benefits.
Nicotine replacement therapy (NRT) increases the chance of successful cessation by 1.5 to two times and this combined with smoking counselling has an even higher success rate.6
NRT should be used with caution in unstable coronary artery disease or uncontrolled hypothyroidism. Care should also be taken with diabetes and hepato-renal diseases. The most common side-effects include nausea and localised skin reactions. Around one in 20 patients become dependent on NRT.
Bupropion, which may cause seizures, has largely been superseded by the more effective varenicline. Varenicline is a partial agonist for the nicotinic acetylcholine receptor and has been advocated by NICE to aid smoking cessation as part of a behavioural programme.7
It reduces the effect of nicotine withdrawal and in addition, attenuates satisfaction from smoking. It should be started one to two weeks prior to the quit date as part of a 12-week counselling programme.
Current recommendations are that if a patient relapses after a course of NRT, bupropion or varenicline, they should not be offered another course for six months. These drugs should not be used in combination. Both bupropion and varenicline may be used in patients with unstable cardiovascular disease but should not be used during pregnancy or breastfeeding, or offered to those under 18 years of age.
The management of patients who smoke is a complex process.
A number of different tools are at hand to help patients quit. With opportunistic screening and motivational support, smoking prevalence will hopefully continue to decline.
- Dr Thakkar is a GP in Wooburn Green, Buckinghamshire
1. Health Act 2006 www.opsi.gov.uk/acts/acts2006/pdf/ukpga_20060028_en.pdf
2. Smoking habits in Great Britain, Office for National Statistics - www.statistics.gov.uk/cci/nugget.asp?id=313
3. Diclemente CC and Prochaska JO. Self-change and therapy of smoking behaviour. A comparison of processes of change in cessation and maintenance. Addictive behaviours 1982; 7: 133-42.
4. Silagy C. Physician Advice for smoking cessation. Cochrane Database Syst Rev 2000; 2: CD000165.
5. Law M and Tang JL. An analysis of the effectiveness of interventions intended to help people stop smoking. Arch Intern Med 1995; 155: 1933-41.
6. Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2004; 3: CD000146.
7. NICE technology appraisal guidance 123 Varenicline for smoking cessation www.nice.org.uk