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Further questions will be needed before the questioner can move forward towards helping the smoker to stop; these will be discussed later, but should include:

• 'Have you ever thought about giving up smoking?'

• If 'Yes', an inquiry about previous attempts and relapses.

What are the barriers to stopping smoking?

Barriers in the smoker

Smokers will not stop smoking unless they want to stop, and also if they believe that they can stop. To want to stop, smokers must acknowledge the advantages of stopping, which will include improved health, saving money, and other individual factors; these may include benefits to their families, feelings of being in control, smelling nicer, and so on. It is valuable to explore these with the smoker, and to record them. Smokers also find it hard to believe that they could stop, because a number of barriers may exist to successful stopping. It is the job of the stop-smoking advisor to understand and look for these barriers, and to help the smoker overcome them.

Addiction

There has always been debate as to whether smoking is a pastime, habit, or a true addiction, and the reality is that different people may be more or less dependent on nicotine. However, for many people, nicotine use does fulfil many of the criteria for substance dependence listed by the World Health Organization International Classification of Diseases (ICD-10). Withdrawal of nicotine is for many smokers extremely stressful, and for a few, virtually impossible. It is clearly easier for less addicted smokers to stop.

Social disadvantage and psychiatric problems

Smoking rates are highest among the poorest social groups, and cessation often poses particular difficulties for socially deprived people for whom daily survival against the odds is the major preoccupation. For many people, smoking is a (relatively) cheap, immediately available pleasure, which may take precedence over other needs and long-term goals. Others who have particular difficulty in stopping include those with psychiatric disorders, including anxiety states, affective disorders, and other psychoses.

Concerns about weight gain

Cigarette smoking has sometimes been promoted as an aid to keeping slim, and smoking may reduce appetite and impair the taste of food. During smoking cessation efforts, weight gain often occurs, perhaps because appetite improves along with an improved sense of taste. Snacking may also be a replacement activity for smoking. On average, weight gain of 4-5 kg can occur in the first year of smoking cessation, and for a few, much greater weight gains may occur. The fear of weight gain can deter the figure-conscious smoker from attempting to stop smoking, particularly among women. Although a lean body image is a high priority, encouraged by the fashion press and often highlighted in tobacco advertising, particularly aimed at women, the risks of mild weight gain are far outweighed by the health risks of smoking. Any weight gain from smoking cessation need only be temporary, and need not occur at all with supportive advice and forewarnings. The use of nicotine replacement therapy and bupropion may reduce the tendency to weight gain.

Physical disease

In studies involving patients with diseases strongly linked to smoking, the occurrence of an acute and often dramatic episode, such as a recent acute myocardial infarction, often resulted in improved cessation rates. On the other hand, those with long-term disabling chronic respiratory disease, including COPD, demonstrated lower success rates in smoking cessation than unaffected people of similar age and sex. Perhaps the people with these chronically progressive diseases who were most likely to stop smoking did so in the earlier stages of their disease, when symptoms first started to have an impact on their lives—while on the other hand, those who did not stop earlier were the more addicted ones, who continued to smoke despite the development of increasingly obvious disability.

Advertising, social pressures

Tobacco manufacturers claim that advertising seeks only to inform smokers of brands, and attempts to switch brand loyalty among smokers. They also claim that advertising plays no part in recruiting new smokers. Despite this, there is good evidence that advertising encourages young people to try smoking, reinforces the social acceptability of smoking, and makes the whole product more attractive. Smokers also find it harder not to smoke if their parents, siblings, work mates or friends smoke, and where smoking forms a part of normal social activities at social gatherings, in pubs, and at work breaks. Such smokers may suffer some degree of social loss by giving up smoking.

Barriers to smoking cessation created by the counsellor

Smokers are more likely to succeed in stopping smoking with the help of an empathetic person who creates a good rapport and shows genuine, uncritical understanding of the smoker's needs and difficulties. The smoking cessation counsellor has to be able to retain enthusiasm for the task despite many failures —and doctors, particularly, are not good at seeing the value of spending time on smoking cessation. Even if they achieve a cessation rate of 10%, the nine out of 10 failures loom large in proportion to the single success, and enthusiasm can evaporate.

What can I do in a few minutes to help COPD patients stop smoking?—the brief intervention

If the average medical consultation in primary care lasts 8min, and hospital doctors are often rushed for time too, the intervention on smoking must be very focused if it is to have any impact. Despite this, studies suggest that even very brief advice to stop, taking 3min of a clinician's time, can increase 6-month cessation rates by about 2%. This means that in the average UK general practice of about 9000 patients cared for by five partners, with 2600 smokers, brief advice could help 50 patients per year to stop smoking. Over the United Kingdom, such simple measures could achieve 300 000 ex-smokers per year in a country with around 12 million smokers. There is no reason why other health professionals, including practice nurses, ward nurses, and health visitors, and also members of the paramedical professions such as physiotherapists, dietitians, pharmacists and others could not have an equal or greater impact. So far there is no evidence as to how effective professionals other than doctors are in giving opportunistic advice and assisting smoking cessation. It seems likely that 'brief intervention' is most likely to be successful with light smokers, smoking 10 cigarettes a day or less. For heavier smokers, additional help or pharmacotherapy (nicotine replacement therapy or bupropion) is likely to be required.

How to undertake the brief intervention

• Ask about smoking habits and history, as detailed above.

• Advise all smokers to consider stopping or stop.

• Assess their smoking habit and how best to:

• Assist the smoker to consider stopping, to prepare to stop, or to take action.

• Arrange follow-up for further support, or referral to specialist cessation service.

When asking about smoking habits, a good early question is, 'Have you ever thought about stopping smoking? If the answer is 'No', then it opens an opportunity to ask what the smoker likes about smoking, what they may dislike about smoking, and whether they see any advantage to not smoking. This may be a good moment to give factual information about the advantages of stopping, with improvements in health and money savings, good example to young people, depending on the individual. Some advisors may find the measurement of exhaled carbon monoxide a useful educational tool at this point. It may be a good moment to assess dependence by asking about the time to first cigarette, as one of the major indicators in the Fagerstrom Test for Nicotine Dependence (FTND) mentioned above. Supportive literature may be provided at this point. The intention is to encourage the smoker to consider the benefits of stopping, with a statement such as 'I'd really like to help you to stop smoking at some point, not too far away, so perhaps we can talk about this again soon, once you have thought about it.'

For the smoker who answers 'Yes' to the question, 'Have you ever thought about stopping?', the next question is, 'Have you ever tried to give up?' If yes, one needs to know about previous attempts to stop, how long the smoker managed to stop, and what happened to start them smoking again. If the smoker has thought of stopping but never actually tried, perhaps because they thought they wouldn't succeed, then it is helpful for the smoker to know that:

1 There are 12 million successful ex-smokers in the UK in a population of 55 million.

2 Most of them report that once they had decided to try to stop smoking, it proved less difficult than they had expected.

3 Most successful ex-smokers have made one or more attempts to stop before they finally succeed in stopping.

The counsellor should express every willingness to help the smoker stop smoking if he or she wants to, in an open, supportive way without criticism or derision.

Having identified a smoker as wishing to give up, the counsellor can assist the smoker by stressing one or more of the 'five Rs':

• Relevant benefits for the smoker

• Risks of continuing to smoke

• Rewards from stopping

• Roadblocks to stopping

• Repeat attempts are more successful.

Finally, it is always good practice to arrange a follow-up visit to discuss progress and give further support. For some patients, much more intensive support and more specialized advice may be needed, and referral to one of the many more specialized smoking cessation support services should always be considered as an addition to brief advice.

How can I understand more and improve success rates?

The majority of successful cessation strategies either result from the smoker's own decision and strategy, often with help from friends or family, or from brief interventions by committed health professionals. Success is encouraged by a supportive environment, which should include the absence of advertising and promotion, and restrictions on smoking in public places and at work, which most smokers support. In addition, there is a place for more specialized smoking advice from trained counsellors who are able to devote more time and expertise to the more addicted smokers. There is strong evidence that experts, spending more time, with regular follow-up and access to the full range of pharmacotherapeutic aids, can achieve the highest success rates. 'Smoking Advice Services' have been established throughout England and in many other areas of the UK to provide easily accessible advice, and try to ensure that the services are available to less affluent groups, who have the highest smoking rates. Telephone support is a further valuable option, together with self-help materials.

Which treatments will increase success rates—nicotine replacement, bupropion, and the rest?

Nicotine replacement therapy

Nicotine replacement therapy (NRT) first became widely available in the form of nicotine chewing gum. Since then, further nicotine delivery methods have become available, including transdermal patches, a nicotine inhaler, nicotine nasal spray, nicotine sublingual tablets and nicotine lozenges (both for buccal absorption). The British smoking cessation guidelines [3,4] offer detailed evidence on the effectiveness of nicotine replacement therapy as an aid to smoking cessation, indicating that use of nicotine replacement therapy doubles the chance of success in smokers who wish to stop. Available delivery systems currently include:

• Nicotine chewing gum, 2 mg and 4 mg strengths.

• Nicotine transdermal patches — delivery over 16h: 5 mg, 10 mg and 15 mg strengths; delivery over 24h: 7mg, 14mg, and 21 mg strengths.

• Nicotine sublingual tablets, 2 mg.

• Nicotine inhalator, 10-mg doses for inhalation.

• Nicotine nasal spray, metered dose inhaler, 0.5 mg per puff. Currently, nicotine replacement therapy is not recommended in pregnancy or in severe cardiovascular disease, and some products are not recommended for people under the age of 18. However, trials of safety and efficacy in such groups are needed, as it is unlikely that nicotine replacement will be more dangerous than the continued smoking it is intended to replace. Indeed, the benefits of stopping smoking may well outweigh the risks of using NRT.

Choosing the best form of NRT for a smoker who wants to stop

There is no clear information as to which type of NRT is most effective, and much depends on patient preference. In medium to heavy smokers, results are best when the higher dose formulations are used initially, such as the 4-mg gum, or the 15-mg, 16-h patch, or the 21-mg, 24-h patch. Many smokers prefer nicotine patches, and do not like chewing gum. It is best to discuss the options with smokers to find their preferences. The theory is that the 24-h patches, applied in the morning, will provide 'cover' until the next morning. Some smokers find that the continued release of nicotine through the night causes side effects such as vivid dreams, insomnia, and other side effects, and such people are likely to tolerate the 16-h preparations better.

It can be argued that the oral or inhaled varieties of NRT, having the quickest delivery after use, may have value in rapidly assuaging cravings in highly addicted smokers. In pregnancy, if cessation seems unlikely with advice alone, one of the oral or sublingual forms of NRT may be considered more appropriate than one of the more persistent dosing systems such as the transdermal patches.

Concurrent use of two or more different types of NRT is not at present recommended, as there have been no studies suggesting whether combined NRT therapies could be helpful. However, the use of different types of NRT together does have some logic, and there are anecdotal accounts of this being helpful to some individual smokers, using a patch for day-long nicotine levels and an oral tablet or lozenge to treat a particular short-term need.

Bupropion

This drug is an atypical antidepressant with both adrenergic and dopaminer-gic actions. Trials of the drug as a smoking cessation aid suggest that if bupropion is started 1 week before cessation, and continued for 7-12 weeks along with intensive support, smoking cessation rates are doubled when compared with placebo. As with other antidepressants, there is a one in 1000 risk of seizures, and epilepsy is regarded as a contraindication to its use. It is also not advised in pregnancy, in people with severe hepatic cirrhosis, with bipolar disorders, anorexia nervosa or people who have had a monoamine oxidase inhibitor (MAOI) within the previous 2 weeks. From trials conducted to date, it is not yet clear whether bupropion is more effective than NRT, whether it is effective without behavioural support, and whether, when used together, bupropion and NRT might be more effective than either treatment alone.

In COPD, there has been one published trial of bupropion; in subjects with relatively mild COPD who volunteered for the study, smoking cessation rates were approximately doubled. However, it may be harder to achieve success in patients with severe COPD.

Other interventions

In addition to NRT and bupropion, clonidine has been shown to have value in smoking cessation treatment, but tends to have more side effects than NRT or bupropion. A variety of antidepressants have also been tried, but without the success rates of NRT/bupropion. There is no good evidence for the value of hypnosis, acupuncture, or any other complementary therapy in smoking cessation.

Table 8.2 Interventions to assist smoking cessation (data from [4]).

Intervention

Group studied

Increase in

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