Health professionals

Smoking in Australia
Health Effects of Smoking
Benefits of Smoking Cessation
Barriers to Smoking Cessation
Helping Smokers Quit
Nicotine Dependence
Pharmacotheraphy for Smoking Cessation
References

Tobacco smoking remains the single most preventable cause of ill health and death in Australia. It contributes to more deaths and hospitalisations than alcohol and illicit drug use combined.1

Smoking rates in the population, 14 years and over have declined to 15.1%. Smoking is higher in people of the lowest socioeconomic status (24.6%) compared to the highest socioeconomic status (12.5%).2

Males are more likely to be daily smokers than females, except in the 12-17 year age group.2

Almost 1 in 5 people aged 20-39 years smoke daily. Indigenous Australians are 2.2 times as likely as non-Indigenous Australians to smoke tobacco.2

It is well documented that second hand smoke is known to cause various health problems in children and adults. Exposure has declined in the last decade, reflecting the decline in smoking rates and an increase in smokers confining their smoking to outside the home.1

Health Effects of Smoking

Tobacco smoke contains many toxic chemicals and at least 69 cause cancer.3

In Australia smoking is the major cause of COPD and lung cancer. Around 40% of smoking related deaths are due to lung cancer and 27% to COPD.Smoking also contributes to worsening of asthma and is a risk factor for cardiovascular disease and stroke.

Tobacco smoking kills more than 15 000 Australians each year, more than breast cancer, AIDS, traffic and other accidents, murders and suicides combined. 5

About 50% of all persistent cigarette smokers are killed by their habit – 25% while still in middle age (35-69 years). On average, cigarette smokers die about 10 years younger than non-smokers. Stopping smoking at age 50 halves the hazard; stopping at 30 avoids most of it. 6

Benefits of Smoking Cessation

The North American Lung Health Study, involving almost 6000 volunteers showed that quitting smoking slowed the accelerated decline of lung function caused by smoking 7,8 . A follow-up at 14.5 years showed that smoking cessation also reduced the rate of mortality from lung cancer, cardiovascular disease and other chronic conditions associated with COPD. Death rates were approximately double in the continuing smokers compared with the sustained quitters.9

There are immediate health benefits to quitting smoking at any age. There are even health benefits to quitting if a person has already been diagnosed with a smoking related disease. Stopping smoking decreases the risk of lung and other cancers, heart attack, stroke and chronic disease compared with continued smoking.10

If a person with COPD is still smoking, the most important thing that they can do to slow the rate of deterioration of their lung function, is to quit. The following graphs shows the effects that smoking, and stopping smoking can have on lung function decline. The set of curves shows normal lung function decline for non-smoking men as well as the risks for death and disability for men who smoke. 11

fletcher_peto_graph

 

This graph can be used to help educate patients about the benefits of quitting smoking and the difference it will make to the rate of lung function decline.

Research has shown that telling smokers their lung age encourages them to quit.12

Lung Foundation Australia has developed an on-line interactive version of the above graph, called the Lung Age Estimator. By entering a smoking patient’s spirometry results (or FEV1 result from a COPD screening device), age, height and gender, a personalised illustration appears demonstrating how much lung function decline can be prevented by getting that patient to stop smoking. The patient will also be given an estimated lung age. This motivational tool can be found with the Primary Care Respiratory Toolkit (hyperlinked to webpage).

Damage to the lungs can’t be completely undone, but most of the adverse health effects from smoking decline rapidly after quitting. Within days, nicotine is removed from the body and carbon monoxide levels fall. Patients will also have an improved sense of taste and smell in a short period of time after quitting. In the months and years following, patients will experience a decrease in their risk of cardiovascular disease and cancer. In general, the mortality and morbidity from numerous conditions and diseases is reduced by quitting smoking.13

Barriers to smoking cessation

The general practice setting is well placed to make a significant difference in smoking cessation with at least 80% of Australians aged over 15 years visiting their GP at least once per year.

There are still some myths that persist preventing some health professionals from following through with smoking cessation advice14 . The most common myths are:

  • Smokers don’t like to be asked about their smoking
  • Most smokers don’t want to quit
  • Brief discussion on smoking cessation doesn’t work. 15

The facts are:

  • The documentation and asking of smoking status is a standard procedure in primary care and patients have come to expect to be asked questions about their smoking. If a health professional fails to ask about smoking status patients believe they are not fulfilling their duty.15
  • Most smoker do want to quit. About 60% of smokers are thinking about or preparting to make a quit attempt.14
  • Research has shown that brief counselling using motivational interviewing techniques is effective in smoking cessation.16 Many patients with COPD are reluctant to make the connection between past lifestyle behaviours such as smoking and their current diagnosis.17

Patients may harbour feelings of guilt, blame and discrimination in relation to their lifestyle choice. To rationalise this, patients may explain the cause of their diagnosis as due to forces outside of their control such as fumes from workplace environments or because of an inherited predisposition rather than the smoking behaviour.17

A patient’s understanding of the causes of their illness has implications for the meaning that they assign to the illness and how they manage their condition. The inability of patients with COPD to recognise smoking as an underpinning factor in the development of their condition will act as a barrier to smoking cessation.17

Whilst patients gather health information from a number of sources it is important to reinforce (with empathy) that smoking is the main cause of COPD.

Stopping smoking is the best thing a patient can do to reduce the rate of lung function decline.

Helping Smokers Quit

Broadly speaking there are three main interventions undertaken to support smokers to quit smoking. These are:

  • Counselling
  • Pharmacotherapy
  • Creating a supportive environment

The following interventions have been shown to be effective in supporting people to stop smoking, including:

Level 1 evidence:

  • Smoking cessation advice from health professionals is effective in increasing quit rates. The major effect is to help motivate a quit attempt.
  • All health professionals can be effective in providing smoking cessation advice.
  • Brief smoking cessation advice from health professionals delivered opportunistically during routine consultations has a modest effect size, but substantial potential public health benefit.
  • Follow-up is effective in increasing quit rates.
  • Pharmacotherapy with nicotine replacement therapy, bupropion or varenicline is an effective aid to assisting motivated smokers to quit.
  • There is no significant effect of acupuncture or hypnotherapy in smoking cessation.

Level 2 evidence:

  • Instituting a system designed to identify and document tobacco use almost doubles the rate of health professional intervention and results in higher rates of cessation.
  • Telephone callback counselling services are effective in assisting cessation for smokers who are ready to quit.

Level 3 evidence:

  • Factors consistently associated with higher abstinence rates are high motivation, readiness to quit, moderate to high self-efficacy and supportive social networks.

Level 4 evidence:

  • Introducing smoking restrictions in the home environment can assist quitting smoking successfully.

Brief intervention doubles the quit rate and more intensive intervention has a larger impact.

  • Nil intervention – 6.4% estimated abstinence rate
  • <3 min GP time – 13.4% estimated abstinence rate
  • 3-10min GP time – 16.0% estimated abstinence rate
  • >10min GP time – 22.1% estimated abstinence rate 13

Brief counselling interventions have been shown to lead to smoking cessation rates of between 5-10% and when delivered by a health professional quit rates are significantly higher than self-initiated strategies.18

Every patient with COPD should have their smoking status reviewed at each visit and be provided with an opportunity to engage in counselling around this issue.23

The currently accepted best practice for smoking cessation support is summarised in the 5-As strategy. The 5-As are well known, commonly used in clinical practice and take at least 3 minutes to complete.19,20

In brief this technique involves:

  1. Ask about smoking – systematically identify and document smoking status.
  2. Advise on the benefits of cessation and processes to make a successful attempt.
  3. Assess interest in quitting, including motivation and confidence, exploration of barriers and level of nicotine dependence.
  4. Assist by working with the patient to develop a plan of action.
  5. Arrange for follow-up with the patient to review progress and prevent relapse.19

See www.racgp.org.au/your-practice/guidelines/smoking-cessation/ for more information.

E-Cigarettes

There is no evidence supporting e-cigarettes as a safer or more effective method than existing, proven, registered, therapeutic quit-smoking methods and medicines. Lung Foundation Australia continues to recommend a smoking cessation strategy which includes clinical counselling together with nicotine replacement therapy or other evidence-based forms of pharmacotherapy. Click here to read the full Lung Foundation Australia position paper on e-cigarettes.

Training for Health Professionals

Lung Foundation Australia’s COPD Online training for nurses contains an entire module that provides more detail for health professionals involved in smoking cessation discussions with patients.

The Lung Health Promotion Centre at The Alfred provides a comprehensive two day Smoking Cessation Course.For further information visit www.lunghealth.org/

The Australian Association of Smoking Cessation Professionals (AASCP) provide a Nicotine Addiction and Smoking Cessation 3-day training course at The University of Sydney. For more information visit: http://aascp.org.au/health-professionals/events/upcoming-accredited-courses/

Health professionals often find it difficult to broach the topic of smoking cessation with their patients.  Start the conversation is an initiative developed through the Supporting Patients to be Smokefree Project that is led by Alfred Health and funded by the Victorian Department of Health.

This campaign primarily addresses clinicians in all health care settings and shares authentic stories about real patients and clinicians. These stories are about the life-changing conversations patients had with their health professionals that led them to stop smoking.  To visit their website and view the video click here.

start the conversation

The NRT – Dispelling the Myths video below was developed by the Queensland Statewide Respiratory Clinical Network’s Smoking Cessation and Tobacco Control Work Group in partnership with Safefood Production Queensland. This video provides information about nicotine replacement therapy (NRT) for clinicians and addresses some of the myths associated with the use of NRT. The content of this video is supported by the Australian Association of Smoking Cessation Professionals.

Smokers that are quitting should be encouraged to avoid situations where others are smoking, especially in the first few weeks. Greatest support is needed in the first few weeks and follow-up with a health professional helps to achieve long-term success.

Nicotine Dependence

Nicotine is the component of cigarette smoke that is responsible for dependence/addiction and inhalation is a highly effective mechanism for delivery of this drug. When administered through the respiratory system nicotine takes 10-19 seconds to reach the brain.13

Whilst nicotine is addictive it is not the component responsible for the harmful effects of smoking. Assessment of nicotine dependence will help in identifying those patients that are likely to experience withdrawal during smoking cessation.13

Withdrawal from nicotine may include craving combined with a variety of other symptoms including:

  • Depressed mood
  • Insomnia
  • Irritability, frustration, anger
  • Anxiety
  • Difficulty in concentration
  • Restlessness
  • Decreased heart rate
  • Increased appetite or weight gain 13

To be classified as experiencing nicotine withdrawal, four of the symptoms above must be exhibited by the patient and cause clinically significant distress. These symptoms usually resolve within 10-14 days, but can persist up to four weeks and for some people thoughts about smoking can linger for years.13

Determining the ‘time to first cigarette’ (TTFC) from waking can help assess nicotine dependence. Smoking within 30 minutes of waking, smoking more than 15 cigarettes per day and a history of withdrawal symptoms in previous quit attempts are all indicators of nicotine dependence.13

The Fagerström Test for nicotine dependence can be used to determine the strength of the nicotine dependency.21 

Pharmacotherapy for smoking cessation

There are three first line medical options available in Australia to assist smokers to quit:

  • Nicotine replacement therapy
  • Varenicline (Champix ®)
  • Bupropion (Zyban ®)22

Nicotine replacement therapy (NRT) aims to reduce the withdrawal symptoms of nicotine addiction so that patients can focus on the psychosocial aspects of smoking cessation. It substitutes for some of the nicotine from cigarettes without the harmful chemical compounds found in tobacco smoke.13 NRT should be recommended to nicotine dependent smokers who express an interest in quitting.13

There is little evidence for its role in those that smoke up to 15 cigarettes a day.23

The evidence for the use of NRT says:

  • Nicotine gum, nicotine transdermal patch, and nicotine inhaler all increase quite rates13 ;
  • In more dependent smokers combinations of different forms of NRT are more effective than one form alone.13 NRT patch and nicotine gum can be used for smokers who have relapsed or who experience withdrawal using only one form of NRT22

NRT is safe to use to help patients to quit smoking:

  • There is no evidence of increased risk in people with stable cardiovascular disease.23
  • There is a lack of association between the nicotine patch and acute cardiac events.
  • There is no increased risk of developing cancer.24
  • The addictive potential of nicotine patches is negligible and significantly less than cigarettes.24
  • NRT is safer than continuing to smoke and can be used for adolescents, pregnant and breastfeeding women.24

Nicotine patches are subsidized through the PBS when participating in support and counselling – one 12 week course of nicotine patches is subsidised per year. Two courses for people who identify as Aboriginal or Torres Strait Islander (under this listing support and counselling is recommended by not mandatory).

Varenicline is subsidised through the PBS for smokers in support and counselling programs – once per year as short term adjunctive therapy for nicotine dependence for up to 24 weeks of continuous therapy (only those who quit at week 12).

Bupropion is supported on the PBS once per year for nicotine dependence for up to 12 weeks of continuous therapy for smokers enrolled in a support and counselling program.

References:

  1. Australian Institute of Health and Welfare 2012. Australia’s health 2012. Australian’s health series no. 13. Cat. No. AUS 156. Canberra: AIHW
  2. Australian Institute of Health and Welfare. 2010 National Drug Strategy Household Survey Report. Drug statistics series no. 25 Cat. No. PHE 145. Canberra: AIHW, 2011. ISSN 1442-7230/ISBN 978-1-74249-188-2.
  3. Tobacco Smoking is Harmful to Health. Treatobacco.net. (Online) March 31, 2011. (Cited: April 5, 2011.) http://www.treatobacco.net/en/page_87.php
  4. Scollo, MM and Winstanley, MH. Tobacco in Australia: Facts and Issue. 3rd Edition. Melbourne: Cancer Council Victoria, 2008. Available from http://www.tobaccoinaustralia.org.au
  5. Australian Institute of Health and Welfare. Australia’s Health 2006. Canberra: AIHW, 2006, cat no. AUS 73.
  6. Doll, R, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ (Clinical research ed). 2004, Vol. 328, p. 1519.
  7. Anthonisen, NR, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1 – The Lung Health Study. JAMA. November 16, 1994, Vol. 272, 19, pp. 1497 – 1505.
  8. Anthonisen, N R, Connett, JE and Murray, RP. Smoking and lung function of lung health study participants after 11 years. Am J Respir Crit Care Med. 2002, Vol. 166, pp. 675-679.
  9. Anthonisen, N R, et al. The effects of a smoking cessation intervention on 14.5 year mortality. Annals of Internal Medicine. February 15, 2005, Vol. 142, 4, pp.233-239.
  10. US Department of Health and Human Services. The health benefits of smoking cessation. A report of the Surgeon General. DHHS Publication No CDC 90-8416. Rockville, MD: US Department of Health and Human Services, Public Health Service, Centres for Disease Control, Centre for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1990. Available from: http://profiles.nlm.nih.gov/NN/B/B/C/T/_/nnbbct.pdf
  11. Fletcher, C and Peto, R. The natural history of chronic airflow obstruction. BMJ. 1977, Vol. 1, pp.1645-1648.
  12. Parkes, G et al. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ. 2008, Vol. 336, pp. 598-600.
  13. Zwar, N, et al. Supporting smoking cessation: a guide for health professionals. The Royal Australian College of General Practitioners. [Online] 2011. [Cited: 11 November 2013.] http://www.racgp.org.au/your-practice/guidelines/smoking-cessation/
  14. Prochaska, J O, et al. Size, consistency and stability of stage effects for smoking cessation. Addict Behav. 2004, Vol. 29, pp. 207-13.
  15. McIvor, A, et al. Best practices for smoking cessation interventions in primary care. Can Respir J. July/August 2009, Vol. 16, 4.
  16. Soria, R, et al. A randomised controlled trial of motivational interviewing for smoking cessation. Brit J Gen Practice. 2006, Vol. 56, pp. 768-74.
  17. Hansen, Emily C, Walters, Julia and Wood-Baker, Richard. Explaining Chronic Obstructive Pulmonary Disease (COPD): perceptions of the role played by smoking. Soiology of Health and Illness. 2007, Vol. 29, 5, pp. 730-49.
  18. GOLD. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Available from: http://www.goldcopd.com
  19. Fiore, M C and Jaen, C R. A clinical blueprint to accelerate the elimination of tobacco use. JAMA. 2008, Vol. 299, 17, pp. 2083-2085.
  20. Fiore, MC, et al. Treating Tobacco Use and Dependence: 2008 Update. US Department of Health and Human Services. (Online) May 2008. (Cited: April 5, 2011.) http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf.
  21. Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine Dependence: A revision of the Fagerstrom Tolerance Questionnaire. British journal of Addictions 1991; 86:1119-27.
  22. Zwar, N et al. Smoking cessation pharmacotherapy: an update for health professionals. Melbourne: The Royal Australian College of General Practitioners, 2007. Reviewed and updated April 2009. ISBN 978-0-86906-288-3.
  23. McKenzie, David, et al. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2013. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Diseae 2013. (Online) 2012. (Cited: August 1, 2013) http://www.copdx.org.au/home.
  24. Zwar, N, et al. Nicotine and nicotine replacement therapy – the facts. Pharmacist. 2006, Vol. 25, 12, pp 969-973