Smoking Cessation

Despite much progress, in 2020, 15.4% of Irish people over 15 years still smoke.  A further 5.8% use e-cigarettes. While evidence shows that patients expect to be asked questions by their health professional about their lifestyle, if they are not asked, they assume that there is not a problem.

In one Healthy Ireland study, only 38% of Irish smokers who attended a health professional in the preceding year reported that the health professional had discussed quitting smoking with them, while 62% missed the opportunity to ‘Make Every Contact Count’.

Pharmacy teams have millions of contacts each year with patients. These are all potential opportunities to empower and support them to make healthier choices, such as to stop smoking.  So how can we be optimally effective in supporting smokers to quit?

The aim of this article is to show you how you can leverage your expertise in smoking cessation products, along with developing consultation skill mastery to increase the number of your patients who quit for good.

Remember: Supporting patients to quit smoking is life-saving work.  One in every two smokers will die from a tobacco related disease and most smokers lose between 10 to 15 quality life years.

At the end of this article, you will be able to:

• Articulate risks and benefits of quitting smoking
• Describe three key factors that may keep people smoking (even when they want to quit)
• Review the role of Nicotine Replacement Therapy (NRT) and other resources to support smoking cessation.
• Apply a 5-STEP framework to communicate and engage with smokers to ‘Make Every Contact Count.’
• Record your learning as CPD in your ePortfolio

What are the benefits of stopping smoking?

Healthcare professionals usually prioritise the health benefits of quitting. However, many smokers may be more motivated to quit by other wellbeing benefits.  (Table 1).

Table 1: Immediate Health Benefits of Stopping Smoking

There are three key factors that influence why people may continue to smoke, even when they want to quit.  How these factors interplay is different for each smoker.  To offer the most appropriate and effective smoking cessation support, you must first help the person understand the degree to which each factor is at play for them.

1. Physical dependence on nicotine

The Fagerstrom Test is a six-question survey to help you determine their level of nicotine dependence. Indicators that a smoker may have a high level of nicotine dependence include smoking soon after waking and smoking more than 20 cigarettes per day.

Smoking Cessation Pharmacotherapies can play a primary role in supporting a person with a high physical dependence to quit.  POM varenicline, NRT 24hr patches and NRT 16hr patches + a quick release NRT formulation are often effective choices.  High dose NRT and varenicline have been shown to have similar abstinence rates after six months, but varenicline shows superior abstinence rates as a monotherapy after one, three and 12 months.

2. Behavioural habits

Smoking is often associated with and reinforced by routine activities, people and situations e.g. at the end of a meal or driving the car. For some people, the feel, smell and sight of a cigarette and the ritual of handling, lighting and smoking it, are all part of the enjoyment and pleasure of smoking. Within a short time, smoking becomes an unconscious habit, that is continually reinforced. For example, a 20/day smoker typically makes the hand to mouth movement 200 times per day (73,000 per year!).

Smoking Cessation Pharmacotherapies that tend to be most effective for smokers with a high behavioural dependency include NRT inhalator or NRT gum. The inhalator replicates the hand to mouth action of smoking. The gum offers an alternative behaviour (chewing). For patients with both a high physical and behavioural dependence, a combination of NRT Patch + NRT inhalator or gum can be useful.

3. Psychological dependence

Smoking is often used as an aid to manage stress and negative feelings of anxiety, frustration or anger. However, because nicotine is a stimulant it doesn’t actually help a person relax.  Many smokers use smoking rituals to give structure to their daily routine by providing breaks.  Smoking is sometimes used to convey confidence or as an ice-breaker in social situations.

For people with primarily psychological dependence, pharmacotherapies tend to play a more supportive role in smoking cessation. In addition to NRT or varenicline to help manage nicotine cravings, it is important to help the person identify the needs that are being met by smoking e.g. “I need to relax,” and explore alternative ways to meet those needs e.g. relax by deep breathing (without a cigarette), distraction or mindfully drinking a glass of water.

Quit rates are enhanced when supported by a supportive environment and development of alternative coping strategies. For this reason, patients should be sign-posted to the HSE Smoking Cessation Service:

• Free Phone: The National Smokers’ Quitline 1850 201 203
• Text: Free text QUIT to 50100
• Website: QUIT.ie where the person can sign up for an online quit plan
• Social Media: facebook.com/HSEquit and Twitter @HSEQuitTeam

The STEPS Consultation Framework provides a framework to build confidence and mastery in hosting these potentially life-saving consultations.

#1 Be Proactive.

• Practice sensitively and directly bringing up the subject of smoking in every consultation (OTC, Rx, beauty counter, phone). g.  “I’d like to ask you about smoking – Have you ever smoked?” 

#2 Demonstrate Empathy. 

• Be genuine, caring and non-judgemental.
• Listen attentively for what is most important to them.
• Reflect the emotion you are hearing back to the person using the phrase ‘sounds like.’ g. ”Sounds like your worried about your children’s health”.

#3 Seek to Understand.

• Ask open questions to see the world through your patient’s eyes. g. “You’ve told me you are a smoker. What do you most enjoy about smoking?”
• Use the Fagerstrom Test to establish physical dependence on nicotine.
• Notice the language they use which may indicate their current Stage of Change in relation to smoking cessation. This is important. Patients need different supports at each stage of change.

Research indicates that 59% of smokers are trying to (Action), planning to (Preparation) or thinking about (Contemplation) quitting.

#4 Problem Solve to Overcome Objections

• Defuse any resistance. Be empathetic, non-judgemental and help your patient open up to possibility. E.g. “I’ve tried to stop so many times in the past and it just doesn’t work”. Response: “You mentioned you’ve already tried to stop many times.  What was your longest time smoke-free?” 
• Support Self-Efficacy. Being able to visualise a smoke-free future is a good motivator and previous efforts and successes can be elicited to build self-confidence. g. “What’s the point – the damage is done already.” Response: “How do you think you would feel if you did stop?”

#5 Then be Understood

• Assess the patient’s starting point, by asking them what they already knowg. “Have you ever heard about risks/harm from second hand smoke?”
• Provide brief advice in small chunks. g. “Quitting smoking is the best thing you can do for you and your family’s health.”
• Check for feedback. E.g. “What questions do you have about what I’ve just shared?”
• Assist the person to select pharmacotherapy and behavioural supports.
• Provide counselling on appropriate use of smoking cessation pharmacotherapies, including selection, correct use, suitable combination treatments (where relevant), duration of treatment, onset of action, interactions with food, drink or other medicines.

#6 Safety Net

• Arrange a follow up appointment within one week.
• Check shared understanding. Ask the patient what their most valuable take-away was from the consultation.
• Reflect on the consultation with a colleague. What worked well? What didn’t go so well? What different approaches could you take next time?

“Supporting patients to quit smoking is life-saving work. One in every two smokers will die from a tobacco related disease and most smokers lose between 10 to 15 quality life years.”