No smoke without fire
Smoking rates may be falling, but with over six million adults still engaging in the habit, there’s still plenty of work to be done to reduce what are, after all, preventable illnesses and deaths
Around 30 years ago, just under 30 per cent of adults in England smoked. Nowadays that figure stands at under 15 per cent, according to Government statistics, though in Scotland, Wales and Northern Ireland it is over 16 per cent. But given that smoking is the number one cause of ill health and premature death – in 2016, there were just shy of 96,000 deaths attributed to smoking across the UK – this number is still too high.
While the overall smoking rate appears to be on the wane – the Government attributes this to continued support of stop smoking schemes, as well as strategies to discourage children from taking up smoking in the first place – the organisation Action on Smoking and Health warns against complacency. It is fair to say that behind the encouraging headlines lie some alarming truths:
- People in more deprived areas are more likely to smoke and less likely to quit
- Smoking is becoming increasingly concentrated in more disadvantaged groups
- Individuals with long-standing mental health problems are twice as likely to be smokers
- Levels of smoking are considerably higher in certain demographic groups, including Bangladeshi, Irish and Pakistani men, and Irish and Black Caribbean women
- There are stark geographical variations: for example, over one in four pregnant women in Blackpool say they are smokers compared to fewer than two in every 100 in Westminster.
The impact of inequalities
All of this means that smoking is the main contributor to health inequalities in the UK. And the health problems caused by smoking are as wide ranging as they are profound. The lungs are an obvious candidate for damage, and certainly the vast majority of lung cancer cases are in smokers, but there is also an increased risk of other cancers, chronic obstructive pulmonary disease (COPD), pneumonia, tuberculosis and asthma.
Other body systems are affected, including the skin; the circulatory system, as smoking makes the heart work harder than it would otherwise; the gastrointestinal system, which becomes more vulnerable to the development of ulcers; and the reproductive system, with fertility being compromised. Even the bones and brain don’t escape unscathed: the former become more brittle, making them more liable to breaking if the individual falls, while less effective blood flow to the brain increases the risk of strokes and aneurysm.
It isn’t just smokers themselves who suffer. Secondhand smoke can cause all kinds of issues, particularly for children who are more likely to experience bronchitis, pneumonia, asthma attacks, meningitis and ear infections. Unborn babies are incredibly vulnerable, with smoking increasing the risk of miscarriage, stillbirth, low birth weight and infant ill health.
No Smoking Day was launched by a charity of the same name in 1984 somewhat fittingly on Ash Wednesday, and it now always takes place on the second Wednesday in March. Ireland has stuck to Ash Wednesday for its annual quit event – perhaps in a country that has traditionally had a Catholic ethos, giving up smoking is a good fit with the start of Lent, the period running up to Easter that has abstinence at its core – under the name National No Smoking Day.
The charity No Smoking Day merged with the British Heart Foundation in 2011, and now the campaign receives funding from the Government as well as various voluntary organisations with an interest in health.
For those not quite ready to quit, there is another diary date that may suit them better: World No Tobacco Day, a World Health Organization campaign that takes place on 31 May each year. And of course, later on in the year, there is Stoptober, the initiative that encourages smokers to make a quit attempt during the month of October.
Righting the wrong
The good news is that it doesn’t take long for the benefits of stopping smoking to be felt. Just 20 minutes after finishing a cigarette, heart rate returns to normal, and after eight hours oxygen levels are back where they should be. After 48 hours, there is no carbon monoxide or nicotine in the body, meaning that taste and smell improve, though this is often the stage at which people who have stopped smoking start to struggle as
the lungs begin to clear out smoking debris – the quitter’s cough. However, breathing becomes easier at the 72-hour mark, due to the bronchial tubes starting to relax, which in turn means energy levels start to climb.
It can take anything from two to 12 weeks for normal circulation to start to be restored, and after three to nine months lung function has increased by up to 10 per cent. The longer-term benefits are really felt shortly after this point: a year post-quitting, the risk of heart disease has halved, after 10 years, the risk of lung cancer has reduced by 50 per cent, and after 15 years, the risk of having a heart attack is the same as that of someone who has never smoked.
Emma Moore, stop smoking advisor, healthy living champion and pharmacy technician at Parade Pharmacy in Chorleywood – the first healthy living pharmacy in Hertfordshire – suggests using visual props to encourage smokers to think about their habit: “Alongside information on our stop smoking service, the damage that can be caused by cigarettes and the benefits of quitting, we put out a box with tar inside it. It means people can see what goes into their lungs when they smoke and many find it quite shocking so then come to us to ask about stopping.”
Emma, who was a finalist at last year’s Recognition of Excellence (RoE) Awards, continues: “A big eye-catching window display is a good way to get people through the door, and we use banners and posters provided by manufacturers of quit aids, national campaigns and organisations. We have leaflets out in several places – on the counter where people might pick them up when they are waiting for their medicines to be dispensed or to buy items at the till, and also where the stop smoking products are displayed.”
Fellow RoE Awards finalist Tyly Roberts says that the first time someone asks about stopping smoking is the most important consultation: “I think it’s a really good idea to start the conversation by asking who wants the person to give up smoking. If it isn’t them, chances are their quit attempt won’t be successful. It has to come from them. That doesn’t mean that someone who has been told to stop – perhaps by a doctor because of a health problem – won’t be able to, but they need to feel that they are doing it for themselves rather than just for other people,” she says.
Pharmacy staff are in a unique position to help customers find their motivation, continues Tyly, who is a healthy living champion and accuracy checking technician, as well as a level 3 smoking cessation advisor, at Rowlands Pharmacy in Bala, Gwynedd. “We often know what is going on in their lives and what matters to them, so can identify reasons that will keep them on track. It might be that they’ve had a baby or new grandchild, got a new job, or a dad wanting to run around with his kids to play football,” says Tyly. “By understanding this at the very first appointment, we can then refer to it as they go through the process.”
Tyly also does something that some might consider a little unusual when supporting people to stop smoking. When people come to her about quitting, she talks to them at length about their reasons and how the scheme works, but then sends them away for 24 hours. She explains: “That way, they and I have an idea of their commitment to quitting.” It also gives an opportunity for the individual to get their head around the need to come to the pharmacy regularly for appointments and mull over the products they are likely to be using, so they can get answers to any questions they might have before they start.
The best chance of success
Tyly’s approach involves giving patients patches in order to suppress background cravings for nicotine – being careful to match the strength and duration to the individual (24-hour products are particularly suitable for those who reach for a cigarette immediately upon waking in the morning, but can cause disturbed sleep) – plus one other form of nicotine replacement therapy to help relieve immediate cravings. “It’s about tailoring to their needs and requirements. Someone who hand rolls their cigarettes might be best off with an inhalator as it gives them something to do with their hands, whereas microtabs might be better for someone who wants or needs a more discreet product,” says Tyly. “I also talk to them about trigger times and suggest new habits to replace smoking. At this time of year, knitting is great because it keeps you indoors when it is cold and wet outside, and it also gives you something to do with your hands.”
An important part of consultations is providing encouragement. “You have to give people self-belief and confidence in themselves: they have to believe that they can do it. Sometimes I talk about success stories I’ve had in the past – maintaining confidentiality, of course – because hearing that someone who is similar to them has managed to stop and stay stopped can make the customer think ‘If they can do it, so can I’,” Tyly explains.
The value of vaping
The place of electronic cigarettes in smoking cessation is sometimes a little unclear: organisations such as NICE cite them as an option, but with the devices not licensed as medicines, some healthcare professionals still have some concerns, particularly about safety.
Darush Attar-Zadeh, a treating tobacco dependence national trainer, has a simple solution: “Whilst I’d always recommend favouring licensed stop smoking aids, because they are medicinal products and so have been through rigorous clinical trails and long-term testing, we can’t ignore the fact that vaping is the most popular option for quitting in the UK now. In fact, it should be encouraged as it is a far less harmful option to smoking because electronic cigarettes contain no tar or carbon monoxide. So if someone completely switches, while we can’t say that there is no harm being caused, it is certainly much, much lower in comparison.
“It is important to tell people going smoke-free that it isn’t the nicotine that is harmful: long-term use of nicotine has been shown to not be a problem, and research suggests that it is actually comparable to long-term use of caffeine. However, because electronic cigarettes contain batteries, some precautions need to be taken, such as not charging devices overnight, using the correct charger, not keeping them in a pocket next to keys and coins, and keeping the liquid well out of the reach of children and pets. Also, dual smoking and vaping is not the same thing – someone who does that is still smoking and won’t achieve the benefits of being a non-smoker.”
Darush, who is also respiratory lead pharmacist at Barnet CCG in North London, recommends looking at resources produced by the National Centre for Smoking Cessation and Training (NCSCT) for more advice. The briefings on e-cigarettes and stop smoking services, as well as working with vape shops, are particularly relevant. He points out: “For every person we help stop smoking, we save a life. Remember, the most successful way of helping a person to stop smoking is a combination of support and treatment, which is available on the NHS. E-cigarettes are definitely part of the solution in the battle to treat tobacco dependence.”
- NHS Smokefree enables people to put together a personalised quit plan
- NHS Live Well has a designated section that provides information and answers commonly asked questions about stopping smoking
- NICE has developed several guidelines on tobacco and smoking
- Action on Smoking and Health has produced a range of fact sheets on topics as diverse as the economics of tobacco to smoking and eye disease
- The National Centre for Smoking Cessation and Training (NCSCT) has briefing documents on a range of topics, including e-cigarettes and working with vape shops.
It doesn’t take long for the benefits of stopping smoking to be felt