Smoking was identified as being among the top five risk factors that cause premature deaths in England according to the Global Burden of Disease study, with the others being poor diet, high blood pressure, obesity and alcohol and drug use (Steel et al, 2018). Following these were air pollution (which is responsible for a quarter of all global cardiovascular disease deaths (World Heart Federation, 2022)) and a lack of exercise (Steel et al, 2018).
In the Long Term Plan, the NHS (2019) committed to helping to make England a smoke-free society by 2023/24, by supporting people who smoke who come into contact with NHS services to quit by offering NHS-funded tobacco treatment services.
Auditing quit support
In 2021, the British Thoracic Society (BTS, 2022) carried out a national audit of the management of tobacco dependency in acute care trusts, following previous audits in 2019 and 2016. The audit included 120 acute hospitals in the UK and analysed 14000 patient records. Nearly 80% of people were asked about their smoking status; only 45% of those were then given the briefest of advice, 15% were offered a referral to a smoking cessation service, 9% were seen by a smoking cessation practitioner while in hospital despite staff knowledge of their addiction, and just 5% of patients provided with the interventions recommended by the National Institute for Health and Care Excellence (NICE): nicotine replacement therapy varenicline and vaping. However, given the context of the last couple of years, perhaps it is understandable why planned smoking cessation implementation took a backseat and were carried out later than planned.
The BTS clincal audit lead, Dr Matt Evison, noted: ‘Most of these initiatives came into being too late for their effect to be seen in our audit, but everything is in place now and we will keep a close eye on the next iteration. While the results are disappointing today, I am looking at this audit as the start, the baseline against which we now need to improve.’
BTS Chair, Dr Paul Walker, commented: ‘The findings of this audit are stark, but the NHS has been under unprecedented strain since we ran the previous audit, which might go some way to explain a slower than expected progress on its commitment to patients who smoke. To fulfil the ambition of the Long Term Plan in smoking cessation, we need enough of the right staff to set up and run tobacco dependence services. It is clear for all to see, though, how success here hinges on a national, long-term workforce planning exercise’.
A way forward
In order to improve smoking cessation service implementation in hospitals, and to share the responsibility with primary care, BTS (2022) made the following recommendations:
- Assess every patient's smoking status
- Appoint a specialist health professional to deliver a tobacco dependency treatment service
- Appoint an executive-level board member to support the service and introduce a data collection system of prescribing with relation to smoking cessation treatments to ensure NICE recommendations are followed
- Introduce a new training package to increase staff competence in delivering effective smoking cessation advice
- Ensure that 90% of tobacco-dependent inpatients receive ‘very brief advice’
- Offer all tobacco-dependent patients a specialist tobacco dependency service referral within the hospital
- Establish a system for monitoring those given very brief advice and referred to tobacco cessation services.
The British National Formulary provides advice on the nurses' formulary for nicotine replacement therapy, highlighting that smoking cessation interventions are cost-effective and can prolong life, and should be offered as appropriate, alongside behavioural interventions for their recovery (Joint Formulary Committee (JFC), 2022). The appropriate therapy can be given according to the person's likely commitment to certain therapies/treatments, availability of counselling and support, previous experience of smoking cessation treatments, appropriateness of pharmacotherapy in light of other medications they are taking or conditions they are living with, and personal preference.
Nicotine replacement therapy
Nicotine replacement therapy is the lowest risk option, introducing few new risks, and can even be abruptly stopped without losing its effectiveness. Following abrupt smoking cessation, it can replace the nicotine the person was used to, while helping with cravings and reducing compensatory smoking. There are multiple choices for the application and formulation of this therapy, which increases the likelihood that there is something suitable for the patient. Patches are convenient due to their long duration and once-daily application. A 24-hour patch is available for those people with particularly strong cravings, and gum, lozenges, sublingual tablets, inhaler, nasal sprays and oral sprays can be used whenever someone feels the urge to smoke, and can prevent cravings while also managing them in the moment (JFC, 2022). People who have tried such products but who have ultimately returned to smoking may find that a combination of therapies suits them best.
Assessment and brief advice
The National Institute for Health and Care Excellence (NICE, 2022) has a guideline for smoking cessation, which details the assessment process. Assessing a person's level of dependence can help to more easily gauge the potential severity of withdrawal symptoms, and tailor a plan of treatment taking this into account. The assessment applies to anyone from the age of 12 years and up. The person should be asked how many cigarettes they smoke each day. The next question should focus on the time the person starts smoking from when they wake, as this establishes the likely severity of cravings and withdrawals. Depending on their answers, a person will receive points and the higher the score, the higher the level of nicotine dependence, and the greater the likelihood of more severe withdrawal symptoms from stopping smoking.
The British Medical Journal (BMJ, 2018) provides a good summary of how to deliver brief advice while delivering smoking cessation intervention in line with best practices. The five As recommended: Ask, Advise, Assess, Assist and Arrange follow-up.
Firstly, systems should be established in any area of healthcare that identify the smoking status of every patient, and practitioners should be able to ask this question, openly reporting this back to the consultant or doctor and specialists the patient is under. The BMJ (2018) then recommends a personalised, open and reflective patient-centred discussion on how smoking cessation can assist a patient in achieving their goals. Next, the patient should be assessed: is the patient ready and willing to stop, and how confident are they about success? Assistance can then be offered, keeping the conversation open for motivational communication if the patient does not yet wish to stop, so they feel they can easily come for advice if they feel ready to take the next step at a later time. Those who are ready should be provided with an appropriate ‘menu’ of pharmacotherapies and counselling therapies. A follow-up can be provided within a week of their stop date through telephone counselling, face-to-face group or individual counselling, or with clinic visits or calls (BMJ, 2018).