Smoking cessation

As a nurse you are in an ideal role to encourage your patients to stop smoking and should make every contact count.

The side effects of smoking tobacco only became noticeable in the 1920s. Many of these adverse effects and life-limiting illnesses are caused by the 4000+ chemicals involved. 

The widespread effects of tobacco smoking affect the whole body, as well as common smoking-related conditions such as chronic obstructive pulmonary disease (COPD) and lung cancer. Second-hand exposure to other people’s tobacco smoke is also a cause of ill health. Smoking in pregnancy can also cause harm as well as risks to children’s future health. 

Third-hand exposure comes from contamination of surfaces with smoke particles. One example is when smoking close to a pet, such as a dog, the particles collect in the fur and can be inhaled/digested when petting or being cuddled. The pet themselves can also be exposed when grooming themselves and are also very susceptible to second-hand smoking damage due to smaller lungs (similar to babies and children).   

Smoking cessation should be seen as a treatment. In a current smoker it is one of the most cost-effective options in chronic disease management. This is especially important in COPD as it is the only intervention that will slow disease progression.

The body starts to recover in as little as 20 minutes when a person quits smoking.

• after 20 minutes blood pressure and pulse start returning to normal
• after 24 hours carbon monoxide is eliminated from the body and the lungs start to clear out smoking debris
• after 48 hours ability to taste and smell improves
• after 3-9 months lung function improves up to 10%
• after 5 years the risk of heart attack falls to about half that of a smoker
• after 10 years the risk of lung cancer is halved and the risk of heart ischaemia falls to that of someone who has never smoked.

Smoking rates have in recent years continued to decline, see: Adult smoking habits in the UK: 2017. However, the harm remains high as tobacco smoking kills over half of its users as well as causing significant long-term damage and distress due to poor quality of life.

Smoking is a relapsing addiction and many people have 6-7 attempts before quitting long term. Receiving behavioural support, for example from a NHS Stop Smoking Service, will quadruple chance of success (NICE, 2018). It is also recommended that behavioural support is combined with nicotine replacement therapy and/or medication.

Nicotine replacement therapy

Nicotine replacement therapy replaces to some extent the nicotine a person would have received from smoking. The dose depends on the amount of cigarettes smoked, intensity and pattern of habit. NICE (2021) recommends a long-acting product (for example, a patch) and a short-acting product of which there are many varieties; these provide a dose of nicotine to help cravings. Most are absorbed sublingually (for example, vaping, gum, spray or inhalator). The dose is usually titrated down over a 12-week period; however, heavy smokers may need longer.

Electronic Nicotine Delivery Devices (ENDDs) including e-cigarettes

ENDDs are electronic devices that mimic cigarettes and release vapor and is commonly known as vaping or electronic cigarettes (e-cigarettes). There are hundreds of different types of devices and juices available. Statutory regulation introduced in 2016 include:

• Consumer products: Manufacturers will need to register products, there are standards that need to be adhered to and advertising is restricted.
• Licensed products: Manufacturers could apply for a medicines license which could then enable prescribing and advertising would be permitted. To date, there are no devices with a license that are being manufactured.   

A common question is whether electronic cigarettes should be recommended by health care professionals. In 2016, Public Health England published a report that indicates that they carry a fraction of the risk of smoking cigarettes, but are not risk-free. However, if a person is smoking tobacco, then we know that they have at least 50% risk of dying from a smoking related disease, often in middle age. Public Health England has since published an update in 2019 regarding the evidence reviewed by leading independent tobacco experts. See: Vaping in England: an evidence update February 2019.

The evidence-base is still evolving and there is a lot of debate for and against e-cigarettes, but there are some excellent resources available which are being updated as new evidence emerges. See: Electronic cigarettes: A briefing for stop smoking services (PDF).

Some people will have switched to e-cigarettes and stopped using tobacco, while others may be using an e-cigarette to quit tobacco. Some may be using both tobacco and e-cigarettes depending on the circumstances and this is referred to as ‘dual use’. We should encourage all and especially the ‘quitter’ to accept a referral to local stop smoking services for support to aid their quit. Receiving behavioural support along with their use of e-cigarettes could improve someone’s long-term chances of quitting tobacco and should be offered.   

As a member on the All Party Parliamentary Group (APPG) on smoking and health, we have been supporting the lobbying on guidance and support on e-cigarettes and how they can best be used to support smoking cessation. See the Government's regulation and guidance on e-cigarettes and vaping. See also the RCN's policy briefing: Revision of European legislation on Tobacco Products Directive. RCN Position Statement (2013).

The European Union and its Member States have taken various tobacco control measures in the form of legislation, recommendations and information campaigns. Tobacco consumption is the single largest avoidable health risk in the European Union. It is the most significant cause of premature death, responsible for nearly 700,000 deaths every year.

The Smoking in Pregnancy Challenge Group has published a new document: Use of electronic cigarettes in pregnancy: A guide for midwives and other healthcare professionals. The briefing is intended to provide a summary of the evidence on electronic cigarettes, with suggested responses to some frequently asked questions about their use during pregnancy. Public Health England has also published a blog: Achieving a smokefree pregnancy: can e-cigarettes help? See also: RCN Midwifery Forum.

The Royal Society for the Prevention of Accidents (ROSPA) has produced guidance on vaping in the home.

Prescription medication

• Varenicline (Champix) is a partial agonist that prevents nicotine reaching receptors, it also releases dopamine to help with cravings. The dose is titrated meaning the person smokes for 8-14 days before quitting. The course of oral tablets is usually 12 weeks. Champix (also called varenicline) is not currently available in the UK or Europe. It has been withdrawn as a precaution because of an impurity found in the medicine. It is not yet known whether it will be available again in the future.
• Bupropion (Zyban) is an older drug not now commonly used. Its primary use was as an antidepressant and it was found the oral tablets had the beneficial side effect of assisting smoking cessation. A course usually lasts 8–12 weeks.

Making every contact count

‘Making every contact count’ is an approach that uses the millions of contacts with individuals that health professionals and organisations have to support them with positive changes for their physical, mental health and wellbeing. This is a responsibility for all health care staff and those working in nursing and midwifery should ensure they have the skills to adopt this approach.

This involves asking about lifestyle, giving brief advice and referring someone on to a service or individual that can provide a more in-depth intervention. It is also referred to as ‘Brief Intervention Advice’ and is summarised:     

What we should be doing

The National Centre for Smoking Cessation and Training (NCSCT) has developed a short training module on how to deliver Very Brief Advice on Smoking. The training module is built around evidence-based behaviour change techniques that provide an understanding of the factors involved in smoking and smoking cessation. The training programme has been shown to increase practitioners' knowledge, develop their skills and lead to improved practice.

The behaviour change techniques contained within the NCSCTs Very Brief Advice (VBA) are:

ASK - all patients if they smoke

ADVISE - the best way to stop

ACT - provide a referral or offer behavioural support and drug treatment

Smoking cessation services

Smoking cessation services need to be available across a range of settings and be flexible to meet public need. Across the UK provision is variable and there are many examples of local areas where there is no access. There are also some examples of quality improvement. See the British Thoracic Society's Smoking cessation resources.   

Referral systems

Referral systems can vary and can be done by contacting local services direct or contacting a national referral system.

In England: Smokefree. Call the Smokefree National Helpline on 0300 123 1044

In Scotland: Stopping smoking. Call the free Smokeline on 0800 84 84 84

In Wales: Help me quit. Call the free Stop Smoking Wales Helpline on 0800 085 2219

In Northern Ireland: Call the stop smoking helpline on 028 9066 3281