Effective cessation interventions

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Primary health professionals play an important role in smoking cessation because you are ideally placed to advise people how to quit and about the support options available to them. This is essential in helping to achieve national ambitions of becoming a smoke-free country in England by 2030 and achieving a tobacco-free generation in Scotland by 2034, as well as meeting targets to reduce smoking in Wales and Northern Ireland.

NICE guidance (NG92) on stop smoking interventions and services recommends that at every opportunity, health professionals should ask people if they smoke and advise them to stop smoking in a way that best suits their preferences.[1]

There are a number of interventions to help people stop smoking. Different cessation tools, including prescribed medication, nicotine replacement therapy (NRT) and e-cigarettes, will work better for different individuals, but we know that quit attempts are more likely to be successful with behavioural support.

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Reference

[1] NICE, Clinical guideline 92: Stop smoking interventions and services. 2018.

Evidence shows that Stop Smoking Services are the most effective way to quit and are one of the most cost-effective interventions in the NHS.[1] Where they are available, they should be considered the first-choice route for people, as they are three times as likely to quit using a Stop Smoking Service compared to going cold turkey.

In some areas, Stop Smoking Services are now offered as part of an Integrated Lifestyle Service, and in others they are still a standalone service. Unfortunately, in areas where services are no longer provided, (which is in part due to Local Authority budget cuts in England), your support is even more valuable. You can help patients to find their local Stop Smoking Service using www.nhs.uk/smokefree.

Reference

[1] NCSCT. Effectiveness and cost-effectiveness of programmes to help smokers to stop and prevent smoking uptake at local level. 2015.

To help people quit, NICE recommend offering advice on nicotine-containing products on general sale to people who smoke and prescribing medication such as varenicline or bupropion[1]. When prescribed by a healthcare professional, NRT can aid in a quit attempt by significantly reducing withdrawal symptoms and cravings. Prescription medications are also shown to improve the success of quit attempts.

When bought over the counter, NRT does not appear to be any more effective at helping smokers quit compared to going cold turkey, which might be due to people not consuming enough nicotine to satisfy their cravings[2]. If bought over the counter, reiterate that the individual should use as much NRT as they need for as long as they need, in order to satisfy their nicotine cravings. Research indicates not enough NRT contributes to quit attempt failures.

References

[1] NICE, Clinical guideline 92: Stop smoking interventions and services. 2018.

[2] Kotz et al, 'Real-world' effectiveness of smoking cessation treatments: a population study. 2014.

Research so far shows that e-cigarettes are far less harmful than smoking [1,2] and there is ever-growing evidence that e-cigarettes are an effective cessation tool.[3-8] They can be an appropriate quitting aid for some people who smoke, including those who have tried and failed to quit previously using other methods. A recent study showed that those using e-cigarettes were 95% more likely to quit than those not using e-cigarettes.[9]

Since they are a new technology, we don’t yet know the long-term impact of e-cigarette use, so it is not recommended that non-smokers start using them. Some toxic chemicals (such as NNALs, acetaldehydes and formaldehyde) have been found in some products, but the evidence suggests their safety profile is far more comparable to that of other NRT products than tobacco.[10,11]

The RCGP and NICE recommend that e-cigarettes should be discussed as an option for smoking cessation. Patients using e-cigarettes should be advised that they need to switch completely rather than becoming ‘dual users’ – using e-cigarettes and smoking. For people using an e-cigarette who want to use other nicotine-containing products at the same time, it is safe to do so.

Non-smokers and young people should avoid using e-cigarettes. It has been argued that e-cigarettes could act as a gateway to taking up smoking cigarettes, but so far, the evidence in the UK does not support this.[12] Youth smoking rates continue to decline and regular use of e-cigarettes by young people who have never smoked in Great Britain is very low at between 0 and 1%.

Read the RCGP 2017 position statement on e-cigarettes

References

[1] Burstyn I. Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks. BMC Public Health. 2014.

[2] Shahab L et al. Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users: A Cross-sectional Study. Ann Intern Med. 2017.

[3] Hartmann-Boyce J et al. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews 2016, Issue 9. 2016.

[4] Liu, X. et al. Efficiency and adverse events of electronic cigarettes: A systematic review and meta-analysis, Medicine, 97(19). 2018.

[5] Beard E. et al. Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time series analysis of population trends. BMJ. 2016.

[6] Statistics on NHS Stop Smoking Services: England, April 2016 to March 2017, 2017.

[7] Brown, J. et al. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction. 2014.

[8] Hajek P. et al. A randomised trial of e-cigarettes versus nicotine-replacement therapy. New England Journal of medicine. 2019.

[9] Jackson SE. et al. Moderators of real-world effectiveness of smoking cessation aids: a population study. Addiction. 2019.

[10] Williams M et al. Metal and Silicate Particles Including Nanoparticles Are Present in Electronic Cigarette Cartomizer Fluid and Aerosol. PLoS ONE 8(3). 2013.

[11] Goniewicz et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco Control. 2013.

[12] Bauld L., MacKintosh A.M., Eastwood B. et al. Young People's Use of E-Cigarettes across the United Kingdom: Findings from Five Surveys 2015-2017. Int J Environ Res Public Health. 2017.

Time can be a barrier when encouraging people to stop smoking, but you could trigger a quit attempt using Very Brief Advice (VBA). VBA is an evidence-based intervention that can be delivered by a health professional, aimed at raising awareness of unhealthy behaviours and encouraging behaviour change in 30 seconds.

NICE recommend all frontline health professionals offer VBA for smoking cessation, [1] but despite this only half of primary care practitioners frequently complete VBA[2].

It is easy to deliver and can be:

  • used opportunistically in almost any consultation without pressing a patient
  • delivered across many consultations to reinforce the message of how to quit
  • can be delivered without prior knowledge of the patient’s smoking habits.

It uses the ‘AAA’ framework - ‘Ask, Advise, Act’ to promote the most effective way to stop smoking and prompt a quit attempt.

Complete our courses to learn how to deliver Very Brief Advice:

Essentials of Smoking Cessation

Behaviour Change and Cancer Prevention

References

[1] NICE, Clinical guideline 92: Stop smoking interventions and services. 2018

[2] Rosenberg G. et al. Smoking Cessation in Primary Care: A cross-sectional survey of primary care health practitioners in the UK and the use of Very Brief Advice. 2019

Complete our 30-min CPD education.

Essentials of Smoking Cessation – module on smoking cessation advice, VBA & types of pharmacotherapy. Useful for those who prescribe and those who provide smoking cessation services.

Behaviour Change and Cancer Prevention - module on how to deliver effective Very Brief Advice for smoking, obesity and alcohol. Useful for all health professionals.

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