Effective ways of supporting patients to stop smoking

Smoking cessation is the most cost-effective intervention for the prevention and treatment of smoking-related diseases. This article discusses the treatments available to support smokers to stop smoking and their efficacy.

Smoking is the primary cause of preventable illness and premature death in the UK, accounting for 81,400 deaths in England in 2009.1 Smoking harms nearly every organ of the body and dramatically reduces both quality of life and life expectancy. Smoking causes lung cancer, respiratory disease and heart disease as well as numerous cancers in other organs including lip, mouth, throat, bladder, kidney, stomach, liver and cervix.

Adults with mental health problems are at particular risk. People in this group smoke 42% of all tobacco in England2 and die on average 16–25 years sooner than the general population, largely due to higher rates of respiratory and cardiovascular illness, and poor survival outcomes from smoking-related illnesses like chronic obstructive pulmonary disease (COPD), which is underdiagnosed and undertreated.3 Patients with schizophrenia have a 28% five-year mortality from COPD compared with a 12% five-year mortality in an age-adjusted population,4 in spite of the fact that over 50% of patients with mental health disorders want to stop smoking.5

In all available studies, supporting patients to stop smoking has been shown to be an effective and highly cost-effective long-term intervention for those with smoking-related long-term disease. Table 1 lists some of the benefits of smoking cessation for a wide range of diseases. Though long, even this list is not exhaustive, and suggests that supporting smokers to quit should be embedded as part of core education and treatment in every sphere of healthcare.

Table 1. Examples of where stop smoking support has been shown to be highly cost-effective and an effective long-term intervention for people with smoking-related long-term disease

Table 2. Strategies used for stopping smoking

Currently available strategies

Strategies for stopping smoking are outlined in Table 2. Stopping smoking unassisted using neither behavioural support nor medication has a poor success rate: only 4% of people quit successfully for at least one year by going ‘cold turkey’.16 Over-the-counter (OTC) nicotine replacement therapy (NRT) has the same success rate as going unassisted (see Figure 1).7 Getting stop smoking medication on prescription alone can almost double the chances of quitting successfully compared with stopping unassisted or getting OTC NRT. The chances of quitting double again using medication together with support from a stop smoking specialist. NHS stop smoking services provide guidance on the most appropriate pharmacotherapy as well as behavioural support, advice and information about coping without a cigarette and managing withdrawal symptoms, making it the most successful strategy for stopping smoking.

Figure 1. Relative success rates of available strategies for smoking cessation.7 NRT = nicotine replacement therapy

Stop smoking pharmacotherapy

The three stop smoking medications approved by NICE are NRT, varenicline (Champix) and bupropion (Zyban).17 These are extremely cost effective and all three medications should be offered as first-line products to smokers who want to stop smoking. None of these medications should be favoured over another unless there are specific contraindications.18

Although NRT can be bought OTC, varenicline and bupropion are prescription-only medications. All three medications should only be prescribed as part of an abstinent contingent treatment in which the smoker sets a quit date and commits to stopping smoking. Only two weeks of medication should be prescribed and further prescriptions should only be given to people who have shown on reassessment that they have remained abstinent or if the clinician and client feel there is a high chance that abstinence will be achieved. Abstinence can be validated either by self-report or by measuring a person’s carbon monoxide level.

NRT

NRT is available as a patch (16 hours and 24 hours duration), mouth spray, chewing gum, lozenges and mini lozenges, inhalator, nasal spray and microtabs (see Table 3). They all come in different strengths and are safe and effective. There are very few contraindications to NRT as it delivers nicotine in a safe form instead of in a cigarette, which delivers nicotine plus tar, carbon monoxide and more than 4000 toxic chemicals, many known to be carcinogenic. Risks and benefits of using NRT should be discussed with pregnant and breastfeeding women and young people under the age of 18 years old.

Table 3. Types of stop smoking pharmacotherapy, including nicotine replacement therapy (NRT), varenicline and bupropion, and their properties (click on table to view full-size) 

The odds ratio (OR) of maintaining long-term abstinence with NRT compared with placebo is 1.84.19 There is little significant difference in the effectiveness of each NRT product. The effectiveness of each product is based on individual preference. However, there is good evidence that using a combination of NRT, preferably a combination of slow-release (eg a patch) and fast-acting (eg an inhalator or mouth spray) products, is more effective than using just single NRT.19

The most common reason for poor efficacy and relapse is that an inadequate amount of NRT has been used. NRT delivers approximately half the amount of nicotine that a cigarette would deliver, therefore it is important for people to use the product frequently (on an hourly basis) and to use the maximum dose in order to maintain blood nicotine levels to make their quit attempt more comfortable and minimise withdrawal symptoms.

Withdrawal from nicotine can be profoundly unpleasant, coming on two to three hours after the last cigarette and peaking two to three days later. Symptoms include an intense craving for nicotine, coupled with any or all of the following: anxiety, depression, drowsiness or trouble sleeping, bad dreams and nightmares, feeling tense, restless or frustrated, headaches, increased appetite and weight gain, and problems concentrating.

Poor technique and incorrect usage of NRT is another common reason for failure. Nicotine gum, for example, is taken by chewing the gum, then resting the pellet between gum and cheek and then chewing again when the taste has faded. Resting the gum allows the nicotine to be absorbed through the lining of the mouth. If the gum is continuously chewed, the nicotine is released too quickly and is then just swallowed, providing only minimal therapeutic effect. It is therefore highly important for people to seek advice and support with an NHS stop smoking service, which can advise them on the best ways of maximising the use of their NRT. Providing smokers with a choice of pharmacotherapy by demonstrating the actual products available facilitates better uptake of treatment by empowering smokers to decide what would work best for them (see Figure 2).

Figure 2. Example of a patient choice box to assist smokers to choose the pharmacotherapy that would best suit them. The box is filled with dummy stop smoking products and a guideline for prescribing is included at the bottom of the box

Varenicline

Varenicline is a nicotinic-receptor partial agonist that helps people to stop smoking by binding the alpha4beta2 subtype of nicotinic acetylcholine receptors, blocking the ability of nicotine to bind (reducing smoking satisfaction) and stimulating the mesolimbic dopamine system (maintaining moderate levels of dopamine to counteract withdrawal symptoms).

Varenicline is indicated for smoking cessation in people over 18 years old, not pregnant and not in renal failure. It is unknown whether varenicline is secreted in human breast milk therefore caution and clinical judgement needs to be taken with pregnant and breastfeeding women. Every smoker who takes varenicline should also receive behavioural support.

A recent study found patients taking varenicline showed statistically superior continuous abstinence rates at weeks 9–12 and 9–24 compared with patients treated with placebo, bupropion or nicotine patch.20

The most common side-effect reported from the use of varenicline is nausea (28.6%). In the majority of cases, the nausea is mild to moderate in severity and generally subsides over time.21

There have been media reports to suggest that varenicline can increase the risk of cardiovascular events and of suicide and is therefore unsafe to be used with people with mental health problems. These reports have, however, been refuted in a meta-analysis, which demonstrated that there was no evidence of an increased risk of suicidal behaviour in patients prescribed varenicline compared with those prescribed NRT.22 In addition, a recent large study demonstrated that the use of varenicline in patients with or without a history of psychiatric disorder is not associated with a significantly increased risk of serious neuropsychiatric adverse events compared with placebo.20

Bupropion

Bupropion is a selective noradrenaline and dopamine reuptake inhibitor. It has antidepressant properties and is indicated as a stop smoking medication for smokers in combination with behavioural support. The odds ratio of bupropion achieving long-term abstinence compared with placebo is 1.82.19 Its efficacy is comparable with single NRT but it has been shown to be less effective than varenicline.

Bupropion is contraindicated in people with seizures or central nervous system tumour, in those who are under 18 years old, pregnant or breastfeeding, those with a previous diagnosis of bulimia or anorexia nervosa, in severe hepatic cirrhosis, bipolar disorder and in people using monoamine oxidase inhibitors (MAOIs).

Side-effects of bupropion can include rash, seizures (0.1%) and increased anxiety and depression. It also has a number of drug interactions and interactions with clinical conditions, therefore caution should be taken before recommending to a smoker.

Electronic cigarettes

The electronic cigarette (e-cigarette) is a battery-powered electronic nicotine delivery device (ENDD) designed for the purpose of providing inhaled doses of nicotine by way of a vaporised solution to the respiratory system. E-cigarettes provide a flavour and physical sensation similar to that of inhaled tobacco smoke, with no smoke or combustion actually involved, although some vapour is released into the air when the smoker exhales. Propylene glycol is typically used to produce the nicotine-carrying vapour.

There are three main types of e-cigarettes or vaporisers (see Figure 3):

‘Cig-a-like’ products This first generation of e-cigarettes was designed to resemble tobacco cigarettes. They sometimes have a light at the end that glows when the user draws on the device to resemble a lit cigarette. They are available either as nonrechargeable disposable models or as an e-cigarette kit that is rechargeable and includes replaceable prefilled cartridges.
‘Tank’ models (also known as ‘vape’ pens) An e-cigarette that is rechargeable and has a tank or reservoir that has to be filled with liquid nicotine.
‘Mods’ (or advanced personal vaporisers) This is a more complex tank model, which can be manually customised by, for example, adjusting the voltage on the device.

Figure 3. Types of e-cigarette. (a) A ‘cig-a-like’ product – a first-generation e-cigarette designed to resemble tobacco cigarettes with a light at the end that glows. (b) ‘Tank’ model (also known as ‘vape’ pen) – a rechargeable device with a tank or reservoir that has to be filled with liquid nicotine. (c) ‘Mods’ (or advanced personal vaporisers) are complex tank models that can be manually customised, eg by changing the voltage on the device

An estimated 2.6 million adults in the UK currently use e-cigarettes (‘vape’).23 E-cigarettes may be used:24–25

• To help quit smoking or avoid relapsing
• To reduce cigarette consumption
• To relieve tobacco withdrawal symptoms in places where there are smoking restrictions
• In order not to disturb other people with smoke
• To continue having a ‘smoking’ experience with reduced health risks
• Because it is cheaper than smoking.

Benefits include the positive effects of abstinence from smoking (less coughing, improved breathing, better physical fitness), enjoyment of the flavour and the sensation of inhalation. Side-effects include dryness of the mouth and throat.26

Evidence on the safety of e-cigarettes is limited, and there is, as yet, no definite evidence regarding the health effects of long-term use. However, numerous studies27 now demonstrate that compared with tobacco products, e-cigarettes are significantly safer for both users and bystanders, there is no excess take up of smoking following their use, and that e-cigarettes can help people to quit smoking and may be contributing to the decline in smoking prevalence. This is important, as the public and smokers are increasingly failing to recognise that e-cigarettes are less harmful than smoking, suggesting that public education on this front still needs addressing.

E-cigarettes were previously regulated as general consumer products, and inconsistencies in product contents and labelling have been of great concern.28 In June 2013, the Medicines and Healthcare products Regulatory Agency (MHRA) announced its intention to regulate e-cigarettes as medicines and under the EU Tobacco Products Directive (TPD), which came into effect from May 2016,29 e-cigarettes containing up to 20mg/ml of nicotine are regulated by the TPD. Levels of 18mg/ml are reported on user websites as suitable for typical smokers.30 NHS stop smoking advisers have still been advised not to recommend that smokers wishing to quit should use e-cigarettes in favour of NHS approved smoking cessation treatments to have the best chances to quit successfully. However, for those smokers who have successfully switched to e-cigarettes, the priority should be staying off conventional cigarettes, rather than quitting e-cigarettes.31

In summary, the role and impact of e-cigarettes has been one of the great debates in public health in recent years. Public Health England (PHE) commissioned an independent review27 of the all the latest evidence to ensure that practitioners, policy makers and, most importantly of all, the public have the best evidence available. From this review, best estimates show that e-cigarettes are 95% less harmful to health than normal cigarettes and, when supported by a smoking cessation service, help most smokers to quit tobacco altogether. Furthermore, the review comprehensively explains the relative risks and benefits of e-cigarettes in terms of harm reduction when compared with cigarettes and as an aid to quitting.

Conclusion

Smoking cessation is the most cost-effective intervention for the prevention of smoking-related disease and treatment for smokers who have smoking-related disease(s). A range of evidence-based treatments exists to support smokers facing the difficulty of behaviour change and breaking nicotine addiction. Supporting smokers to quit, knowing and using these interventions, is every clinician’s business.

References

1. HM Government. Healthy lives, healthy people: A tobacco control plan for England. March 2011. www.gov.uk/government/publications/the-tobacco-control-plan-for-england
2. HM Government. No health without mental health: a cross-government mental health outcomes strategy for people of all ages. February 2011. www.gov.uk/government/publications/the-mental-health-strategy-for-england
3. Health Development Agency. Smoking and patients with mental health problems. April 2004. http://www.webarchive.org.uk/wayback/archive/20140616174051/http://nice.org.uk/nicemedia/documents/smoking_mentalhealth.pdf
4. Jones DR, et al. Prevalence, severity and co-occurrence of chronic physical health problems of persons with serious mental illness. Psychiatric Services 2004;55:1250–7.
5. Jochelson K, Majrowski B. Clearing the air: debating smoke free policies in psychiatric units. Kings Fund. July 2006. www.kingsfund.org.uk/publications/clearing-air
6. Critchley JA, et al. Life-years gained from coronary heart disease mortality reduction in Scotland: prevention or treatment? J Clin Epidemiol 2003;56:583–90.
7. Hoogendern M, et al. Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD. Thorax 2010;65(8):711–8.
8. IMPRESS. Guide to the relative value of interventions for people with COPD. 2012.
9. Au DH, et al. The effect of smoking cessation on the risk of chronic obstructive pulmonary disease exacerbations. J Gen Int Med 2009;24:457.
10. Kawachi I, et al. Smoking cessation and decreased risk of stroke in women. JAMA 1993;269:232–6.
11. Critchley JA, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database of Systemic Reviews 2003;4:CD003041.
12. Suskin NS, et al. Relationship of current and past smoking to mortality and morbidity in patients with left ventricular dysfunction. J Am Coll Cardiol 2001;37(6):1677.
13. Nyhäll-Wålin BM, et al. High disease activity disability burden and smoking predict severe extra articular manifestations in early rheumatoid arthritis. Rheumatology 2009;48(4):416–20.
14. Quick CRG, Cotton LT. The measured effect of stopping smoking on intermittent claudication. Br J Surgery 2005;69(S6):24–6.
15. Dogar O, et al. Smoking cessation and respiratory disease in low-income and middle-income countries. Lancet Respir Med 2013;1(5):e23–4.
16. Hughes JR, et al. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004;99:29–38.
17. West R, Brown J. Smoking and smoking cessation in England 2011. April 2012. www.smokinginengland.info
18. National Institute for Health and Care Excellence. Stop smoking services. PH10. February 2008 (updated November 2013). www.nice.org.uk/guidance/ph10
19. Cahill K, et al. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database of Systematic Reviews 2013;5:CD009329.
20. Anthenelli RM, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomized, placebo-controlled clinical trial. Lancet 2016;387(10037):2507–20.
21. Cahill K, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews 2011;2:CD006103.
22. Thomas KH. Smoking cessation treatment and risk of depression, suicide, and self harm in the Clinical Practice Research Datalink: a prospective cohort study. BMJ 2013;347:f5704.
23. ASH. Electronic cigarettes (also known as vapourisers). February 2016 http://ash.org.uk/stopping-smoking/ash-briefing-on-electronic-cigarettes-2/
24. Etter JF, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction 2011;106(11):2017–28.
25. Caponnetto P, et al. The emerging phenomenon of electronic cigarettes. Expert Rev Respir Med 2012;6(1):63–74.
26. Etter JF. Electronic cigarettes: a survey of users. BMC Public Health 2010;10:231.
27. McNeill A, et al. E-cigarettes: an evidence update. A report commissioned by Public Health England. August 2015. https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update
28. ASH Scotland. E-cigarettes. August 2010. http://www.ashscotland.org.uk/
29. European Commission. Revision of the tobacco products directive. March 2014. http://ec.europa.eu/health/tobacco/products/revision_en
30. See for example: www.learn.eversmoke.com/nicotine-strength.html; www.vapertrain.com/page/hdics; www.vapehit.co.uk/info.php?articles&articles_id=22
31. Foulds J, et al. Electronic cigarettes (e-cigs): views of aficionados and clinical/public health perspectives. Int J Clin Prac 2011;65(10):1037–42.

Declaration of interests

None to declare.

Elizabeth Pang is stop smoking specialist and self-management
support and behaviour change manager and Myra Stern is a
consultant respiratory physician, Whittington Health, London

Effective ways of supporting patients to stop smoking

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