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VOLUME 8 NUMBER 3 • SEPTEMBER 2011
HANDS ON
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Key initial advice to give on smoking cessation
The five As approach can be useful when offering initial advice:
Ask
•
about smoking and record smoking status
Advise
•
patients of the health benefits of quitting
Assess
•
willingness to stop
Assist
•
smokers who are keen to stop to choose the best method for them
Arrange
•
support, follow-up and monitor progress
(Further information:
Smoking and lung cancer trends over time
What are the stages in achieving behavioural changes?
The most effective method of quitting combines support to help people
change their behaviour, together with pharmacological interventions such
as NRT, bupropion and varenicline.
The Department of Health advises that all of these methods should
be made available to patients, matching each intervention to their indi-
vidual needs by bearing in mind previous attempts to quit, the amount
they currently smoke and the cost (including the cost-efficiency) of each
intervention.
Research has shown that simple advice will help one in 40 people quit
smoking. Using NRT on top of this will increase the quit rate to one in 20.
Other interventions such as bupropion or varenicline will mean that the
numbers needed to treat (ie the number of people who are treated for one
person to quit smoking) are 15 and eight, respectively.
ACHIEVING BEHAVIOURAL CHANGE
Clear guidance on helping smokers to quit is available from the
Department of Health and the National Institute for Health and Clinical
Excellence (NICE), amongst other organisations (see More Informa-
tion). The model of change as described by Prochaska and Diclemente
has been used to explore many types of behavioural change includ-
ing smoking cessation and can be helpful in looking at the processes
involved.
The model explains the importance of recognising where any individual
stands within the cycle of change, from pre-contemplation to contem-
plation, preparation, action, maintenance and relapse. Entry to and exit
from the cycle can occur at any stage. Importantly, relapse is recognised
as being a normal part of the cycle of change – which fits with real-life
experience as, on average, smokers take four or more attempts before
they manage to quit for good. Coping with relapse should, therefore, be
included in any discussion with smokers about quitting. Explaining that
each relapse brings the patient closer to success next time should go
some way to helping to prevent them becoming demoralised.
PHARMACOLOGICAL INTERVENTIONS
Nicotine replacement therapy
NRT is available on prescription or can be bought over the counter in
supermarkets and chemists. NRT products have been licensed for use
in the UK since the early 1980s. They have been shown to be very safe
and it is useful to note that their use is much safer than continued use of
nicotine from cigarettes. They deliver a steady dose of nicotine to the pa-
tient while preventing exposure to the other hazardous substances found
in cigarette smoke if the person had otherwise continued to smoke.
NRT can be delivered by a variety of systems including patches, gum,
lozenges and inhalators, among others. In heavy smokers, or those who
have failed to quit previously, NRT can also be used as combinations of
products, specifically using patches to deliver a background dose of nico-
tine while using back-up methods such as gum, lozenges or the inhalator
to provide short extra bursts of nicotine during cravings.
It is generally recommended that patients use NRT for up to 12 weeks
and that the dose of nicotine is slowly reduced over this period, leading to
eventual withdrawal from treatment. However, it is important to remember
that NRT is much safer than smoking so it is better to maintain the patient
on NRT for longer if necessary than for them to return to smoking. NRT is
licensed for use in smokers aged 12 years and over, and is also licensed
