ISSN 2043-7684 | Vol 7 Issue 4
Inspiration in smoking cessation
Winners of The Advisor Team of the Year Awards 2016
The added risks smokers face when undergoing surgery
Why older smokers are worth targeting
Denmark sets 2030 target for its first smoke-free generation
For more stop smoking news, views and features visit www.theadvisoronline.co.uk
Johnson & Johnson Limited has provided an educational grant
to support the production and distribution of this publication.
Supported by Pfizer
HOW DO YOU
EMPOWER THEM
TO QUIT FOR GOOD?
Combination NRT is 43% more
effective than patch alone
1
Nothing beats NICORETTE dual support
®
1
Odds ratio 1.43 (95%Cl 1.08 to 1.91)
1. Cahill et al, Cochrane summaries, 2013
Nicorette Invisi Patch Prescribing Information: Presentation: Transdermal
delivery system available in 3 sizes (22.5, 13.5 and 9cm2) releasing 25mg, 15mg
and 10mg of nicotine respectively over 16 hours. Uses: Nicorette Invisi Patch
relieves and/or prevents craving and nicotine withdrawal symptoms associated with
tobacco dependence. It is indicated to aid smokers wishing to quit or reduce prior to
quitting, to assist smokers who are unwilling or unable to smoke, and as a safer
alternative to smoking for smokers and those around them. Nicorette Invisi Patch is
indicated in pregnant and lactating women making a quit attempt. If possible,
Nicorette Invisi Patch should be used in conjunction with a behavioural support
programme. Dosage: It is intended that the patch is worn through the waking hours
(approximately 16 hours) being applied on waking and removed at bedtime.
Smoking Cessation: Adults (over 18 years of age): For best results, most smokers
are recommended to start on 25 mg / 16 hours patch (Step 1) and use one patch
daily for 8 weeks. Gradual weaning from the patch should then be initiated. One 15
mg/16 hours patch (Step 2) should be used daily for 2 weeks followed by one 10
mg/16 hours patch (Step 3) daily for 2 weeks. Lighter smokers (i.e. those who
smoke less than 10 cigarettes per day) are recommended to start at Step 2 (15 mg)
for 8 weeks and decrease the dose to 10 mg for the final 4 weeks. Those who
experience excessive side effects with the 25 mg patch (Step 1), which do not
resolve within a few days, should change to a 15 mg patch (Step 2). This should be
continued for the remainder of the 8 week course, before stepping down to the 10
mg patch (Step 3) for 4 weeks. If symptoms persist the advice of a healthcare
professional should be sought. Adolescents (12 to 18 years): Dose and method of
use are as for adults however, recommended treatment duration is 12 weeks. If
longer treatment is required, advice from a healthcare professional should be
sought. Smoking Reduction/Pre-Quit: Smokers are recommended to use the patch
to prolong smoke-free intervals and with the intention to reduce smoking as much
as possible. Starting dose should follow the smoking cessation instructions above
i.e. 25mg (Step 1) is suitable for those who smoke 10 or more cigarettes per day
and for lighter smokers are recommended to start at Step 2 (15 mg). Smokers
starting on 25mg patch should transfer to 15mg patch as soon as cigarette
consumption reduces to less than 10 cigarettes per day. A quit attempt should be
made as soon as the smoker feels ready. When making a quit attempt smokers who
have reduced to less than 10 cigarettes per day are recommended to continue at
Step 2 (15 mg) for 8 weeks and decrease the dose to 10 mg (Step 3) for the final 4
weeks. Temporary Abstinence: Use a Nicorette Invisi Patch in those situations when
you can’t or do not want to smoke for prolonged periods (greater than 16 hours). For
shorter periods then an alternative intermittent dose form would be more suitable
(e.g. Nicorette inhalator or gum). Smokers of 10 or more cigarettes per day are
recommended to use 25mg patch and lighter smokers are recommended to use
15mg patch. Contraindications: Hypersensitivity. Precautions: Underlying
cardiovascular disease, diabetes mellitus, renal or hepatic impairment,
phaeochromocytoma or uncontrolled hyperthyroidism, generalised dermatological
disorders, gastrointestinal disease. Angioedema and urticaria have been reported.
Erythema may occur. If severe or persistent, discontinue treatment. Stopping
smoking may alter the metabolism of certain drugs. Transferred dependence is rare
and less harmful and easier to break than smoking dependence. May enhance the
haemodynamic effects of, and pain response, to adenosine. Keep out of reach and
sight of children and dispose of with care. Should be removed prior to undergoing
MRI procedures. Pregnancy and lactation: Only after consulting a healthcare
professional. Side effects: Very common: pruritus. Common: headache, dizziness,
nausea, rash, urticaria, vomiting. Uncommon: hypersensitivity, palpitations, urticaria,
paraesthesia, tachycardia, flushing, hypertension, hyperhidrosis, myalgia,
application site reactions, asthenia, chest discomfort and pain, malaise, fatigue,
dyspnoea. Rare: Anaphylactic reaction, GI discomfort, angioedema, erythema, pain
in extremity. Very rare: reversible atrial fibrillation. See SPC for further details. NHS
cost: 25mg packs of 7: £10.37, 25mg packs of 14: £17.00, 15mg packs of 7:
£10.37, 10mg packs of 7: £10.37. Legal category: GSL. PL holder: McNeil
Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG. PL numbers:
15513/0161; 15513/0160; 15513/0159. Date of preparation: May 2016
nicotine
Nicorette QuickMist Prescribing Information: Presentation: oromucosal spray.
Each 0.07ml contains 1mg nicotine, corresponding to 1mg nicotine/spray dose.
Uses: relieves and/or prevents craving and nicotine withdrawal symptoms
associated with tobacco dependence. It is indicated to aid smokers wishing to quit
or reduce prior to quitting, to assist smokers who are unwilling or unable to smoke,
and as a safer alternative to smoking for smokers and those around them. It is
indicated in pregnant and lactating women making a quit attempt. Dosage: Adults
and Children over 12 years of age: the patient should make every effort to stop
smoking completely during treatment with Nicorette QuickMist. One or two sprays
to be used when cigarettes normally would have been smoked or if cravings
emerge. If after the first spray cravings are not controlled within a few minutes, a
second spray should be used. If 2 sprays are required, future doses may be
delivered as 2 consecutive sprays. Most smokers will require 1-2 sprays every 30
minutes to 1 hour. Up to 4 sprays per hour may be used; not exceeding 2 sprays per
dosing episode and 64 sprays in any 24-hour period. Nicorette QuickMist should be
used whenever the urge to smoke is felt or to prevent cravings in situations where
these are likely to occur. Smokers willing or able to stop smoking immediately
should initially replace all their cigarettes with the Nicorette QuickMist and as soon
as they are able, reduce the number of sprays used until they have stopped
completely. When making a quit attempt behavioural therapy, advice and support
will normally improve the success rate. Smokers aiming to reduce cigarettes should
use the Mouthspray, as needed, between smoking episodes to prolong smoke-free
intervals and with the intention to reduce smoking as much as possible.
Contraindications: children under 12 years of age and hypersensitivity to any of the
ingredients. Precautions: unstable cardiovascular disease, diabetes mellitus, G.I
disease, uncontrolled hyperthyroidism, phaeochromocytoma, hepatic or renal
impairment. Stopping smoking may alter the metabolism of certain drugs.
Transferred dependence is rare and both less harmful and easier to break than
smoking dependence. May enhance the haemodynamic effects of, and pain
response to, adenosine. Keep out of reach and sight of children and dispose of with
care. Pregnancy & lactation: smoking cessation during pregnancy should be
achieved without NRT. However, if the mother cannot (or is considered unlikely to)
quit without pharmacological support, NRT may be used after consulting a
healthcare professional. Side effects: Very common: headache, cough, throat
irritation, nausea, hiccups. Common: toothache, hypersensitivity, burning sensation,
dizziness, dysgeusia, paraesthesia, abdominal pain, diarrhoea, dry mouth,
flatulence, salivary hypersecretion, stomatitis, vomiting, dyspepsia, fatigue.
Uncommon: abnormal dreams, palpitations, tachycardia, flushing, hypertension,
bronchospasm, dysphonia, dyspnoea, nasal congestion, sneezing, throat tightness,
eructation, glossitis, oral mucosal blistering and exfoliation, paraesthesia oral, dry
skin, urticaria, angioedema, hyperhidrosis, pruritus, rash, erythema, pain in jaw,
asthenia, chest discomfort and pain, malaise, oropharyngeal pain, rhinorrhea,
gingivitis, musculoskeletal pain, hyperhidrosis. Rare: dysphagia, hypoaesthesia oral,
retching. Not known: atrial fibrillation, anaphylactic reaction, blurred vision,
lacrimation increased, dry throat, GI discomfort, lip pain, muscle tightness,
angioedema, erythema. NHS cost: 1 dispenser pack £12.12, 2 dispenser pack
£19.14. Legal category: GSL. PL holder: McNeil Products Ltd, Roxborough Way,
Maidenhead, Berkshire, SL6 3UG. PL number: 15513/0357. Date of preparation:
June 2016.
Adverse events should be reported. Reporting forms and
information can be found at www.mhra.gov.uk/yellowcard.
Adverse events should also be reported to
McNeil Products Limited on 01344 864 042.
Date of Preparation: August 2016 UK/NI/16-7355
CONTENTS
Editor’s welcome
T
his issue we announced the winners of the
2016 Advisor Awards (pages 9-11). We
received a diverse range of entries, but most
the teams had one thing in common; they
were attempting to engage with hard-to-reach
and challenging groups. What this shows is
that stop smoking services are increasingly
targeting populations who may have been
overlooked in the past but probably have the
most to gain from quitting.
One large group that is frequently ignored is
older smokers, because other groups are seen
as a priority, and there is often a perception
that it is too late for older smokers as the
damage has already been done, their addiction
is entrenched and they have few other
pleasures. But, as our Unravelled feature (pages
16-17) points out, it is well worth targeting
older smokers. Older smokers will still reap
6
plenty of benefits from quitting, and those that
attempt to quit are generally more successful
than younger smokers, perhaps because they
are more in touch with the fragility of life and
may be experiencing some of the adverse
health consequences of their addiction.
Looking at the other end of the age
spectrum, Dispensing Insight (page 8)
describes how advisors’ can draw on clients’
childhood experiences to make parallels with
smoking and quitting, highlights skills and
resources that clients have used in the past
and can employ again in a quit attempt.
More and more cash-strapped clinical
commissioning groups have begun to talk
about denying routine operations to people
who smoke or who are overweight, unless they
make lifestyle changes. While denying surgery
to a smoker is contrary to guidelines, there are
News
5 A round up of the latest stop smoking stories.
Corner shop profits protected despite tobacco
sales drop; Law to ban smoking in cars with
children working well surveys by ASH find; 40 per
cent of retailers illegally sell e-cigarettes to under18s; Regular use of e-cigarettes by teenagers
remains low; ASH calls for funding boost to
support stop smoking media campaigns; Smoking
rates in people with serious mental ill health
almost three times the national average; Secondhand smoke dangers initiative will tour deprived
areas; Parental absence during childhood linked
to smoking and drinking before teenage years;
PLUS Butt Busters news bites.
Features
© Red Gravity Publishing Ltd. 2016
The Advisor, PO Box 467, West Byfleet, KT14 9BU
The Advisor® is produced as an aid to stop smoking
services to assist with information for clients who
wish to stop smoking or reduce their tobacco use.
Information contained in this publication should
be used in conjunction with other sources of
clinical evidence and product literature.
Publisher: Red Gravity Publishing Ltd.
Editor: Ingrid Torjesen
Editorial Consultant: Dr Alex Bobak
Publications Manager: Annie Wheeler
Designer: Duncan Norton
Printed by: Central Colour Ltd., Nottingham
Johnson & Johnson Ltd and Pfizer Ltd have
had no input into the editorial content of
this publication.
Editorial content has been produced and
edited by Red Gravity Publishing without input
or influence from the sponsoring companies.
The views expressed in this publication are
not necessarily those of the editorial team, the
publisher, or the sponsor.
4
The Advisor | Winter 2016
plenty of reasons why it is a good idea for a
smoker to stop, at least temporarily, if they have
surgery planned (Clinical Focus, pages 14-15).
Denmark’s ambition to raise its cancer
survival rates, which are among the worst
in Europe, to levels similar to those of its
Scandinavian neighbours, which are among the
highest, is the driver for a new focus on smoking
cessation (as in How they do it in ..., pages
20-21). And finally, The Advisor learns how stop
smoking services in Kent are achieving quit
rates in patients with mental health issues that
are on a par with those attained in the general
population (The Clinic, page 18-19).
Ingrid Torjesen
9
Regulars
8 Dispensing Insight.
Michael J Walsh, a pharmacist in Northern
Ireland, shares tips for helping smokers quit in
his regular column.
14Clinical Focus.
Operation quit. While denying smokers
operations may be unethical and contrary to
guidelines, there are numerous reasons why
it makes sense for smokers to quit, at least
temporarily, before going into theatre.
9 Advisor Awards 2016.
The Advisor announces the winners of its
annual stop smoking service awards, which are
now in their fourth year.
16 Unravelled.
Old dog, successful quit. Older smokers are
rarely targeted for quit attempts because there
is a view that their addiction is entrenched,
the damage has been done and they have few
other pleasures, but this is a mistake because
they tend to be more successful at quitting than
younger groups.
22Dates for your diary.
Upcoming stop smoking events and training.
18The Clinic.
Quit Positive. The Advisor learns how stop
smoking services in Kent are achieving quit rates
in patients with mental health issues that are on a
par with those attained in the general population.
20 How they do it in...
Denmark. With cancer survival rates close to
the worst in Europe, this Scandinavian country
has launched a new cancer plan with a focus on
smoking cessation and a goal of creating its first
smoke-free generation by 2030.
22Your questions answered.
Jennifer Percival solves problems in the clinic.
23 Butt Ends.
Helen Shields describes how stop smoking
services in Nottinghamshire are targeting the
smoke-free message to primary school children
and their parents.
14
NEWS
Corner shop profits protected
despite tobacco sales drop
Profits made by small retailers in corner shops
are mostly unaffected by falling sales of tobacco
products, according to anti-smoking campaigners.
Research commissioned by Action on
Smoking and Health (ASH) shows that corner
shops make, on average, a profit of only £242 a
week on tobacco products compared to £2,611
from everything else that they sell.
The figures, which come from Counter
Arguments: How important is tobacco to small
retailers?, a joint project with the National
Centre for Addiction at King’s College London,
show that tobacco sales are declining fast and
most small retailer transactions
(79 per cent) do not include the
purchase of tobacco products.
Data obtained from the
electronic point of sale system
(EPOS) of a sample of 1,447 small
shops in the UK over one week
were analysed and the results
showed that the average profit
margins for retailers were only
6.6 per cent for tobacco products
compared to 24.1 per cent for all
other products.
Alongside the analysis, ASH
carried out a telephone survey of
591 local newsagents, from which more than
two thirds (69 per cent) admitted that they only
made small profits from tobacco product sales.
ASH said that its research showed how
tobacco industry messaging related to small
retailers exaggerated the need for tobacco sales
and the impact it had on profits.
ASH chief executive Deborah Arnott said:
‘Tobacco is a high-cost, low-profit product, and
money spent on tobacco is money not available
for other more profitable purchases. Our report
invites retailers to see the long-term decline in
smoking as an opportunity, not a threat.’
Law to ban smoking in cars with children
working well, surveys by ASH find
Teenagers say the law banning smoking in
cars with children under the age of 18 present
is working well, and it appears to be popular
one year after coming into effect.
Health charity ASH (Action on Smoking and
Health) has published the results of its ASH
Smokefree Youth Great Britain Survey 2016 of
2,331 young people aged 11 to 18.
The results showed that 86 per cent of
children reported no exposure to smoking in
cars compared to 83 per cent the previous year.
Support for the law has also increased
since the legislation was implemented on
1 October 2015.
The accompanying ASH YouGov Smokefree
GB Survey 2016, which contains results
from 10,058 adults, found that the law was
supported by 87 per cent of adults in England
– a 2 per cent increase on last year’s survey.
There was also growing support for
legislation to cover smoking in all cars. Almost
two thirds (62 per cent) of adults in England
reported supporting this measure in 2016
compared to 59 per cent the previous year,
the survey showed.
Deborah Arnott, ASH chief executive,
said: ‘The evidence is clear that people are
complying with this popular law which
protects children from the harm caused by
second-hand smoke. But adults are also at risk.
‘Prohibiting smoking completely would
make the law simpler to enforce as well as
protecting all car occupants from the serious
harm caused by tobacco smoke.’
However, the Police Federation of England
and Wales said that in the last 12 months,
there had been minimal fines or court
summons issued for people breaking this law.
Jayne Willetts, Federation lead on roads
policing, said: ‘It’s been really difficult for our
members to enforce this law, because since the
change of legislation, police have still yet to be
given the power to issue a Fixed Penalty Notice.’
40 per cent of
retailers illegally
sell e-cigarettes to
under-18s
An official investigation has found that almost
40 per cent of retailers in England have sold
e-cigarettes and vaping liquids illegally to
children and young adults.
The Nicotine Inhaling Products (Age of Sale
and Proxy Purchasing) Regulations 2015 came
into force in October 2015 and prohibit sales to
under-18s, except under certain circumstances.
A total of 634 compliance tests were
conducted between January and March of this
year by English trading standards services,
supported by the Department of Health and
managed by the Chartered Trading Standards
Institute (CTSI).
The results showed that illegal sales were
made on 246 occasions, meaning that the overall
rate of non-compliance was 39 per cent.
Businesses tested included independent
pharmacies, specialist e-cigarette suppliers,
discount stores and markets, as well as
traditional tobacco retailers.
A variety of products, from e-liquids and
disposable e-cigarettes to rechargeable
products, were purchased, with prices ranging
from £1 to £20.
In places where an illegal sale was made,
further advice and guidance were given to help
the business comply.
Leon Livermore, CTSI chief executive, said that
although the results were disappointing, it was
important to consider them in context.
‘More than 2.5 million adults use electronic
cigarettes and evidence suggests the products
are now the most popular quitting aid for
smokers in England.
‘These products are being sold in a wide
variety of retailers and many of them will
have little or no experience of challenging age
restricted sales.’
Winter 2016 | The Advisor
5
NEWS
Regular use of e-cigarettes
by teenagers remains low
The number of teenagers trying e-cigarettes
has grown in the past year but regular use is
still low, according to figures released by ASH
(Action on Smoking and Health).
The results from the ASH/YouGov Smokefree
Youth Survey 2016, which include responses
from 2,311 children aged 11 to 18, show that
experimentation has increased over the last
three years, with 9 per cent of 11-18 years olds
saying they had tried e-cigarettes ‘once or twice’
in the past year, up from 6 per cent in 2014.
However, regular use of the devices
remained rare across all three
years with only 2 per cent of
young people saying they used
e-cigarettes more than once a
month in 2016.
ASH said that during this
period, there has been a fall
in smoking among children, in
contrast to suggestions that
e-cigarette use can lead to a
take-up of smoking.
The survey also found that in
2016, only 5 per cent of 11-18
year olds said they had not
heard of e-cigarettes, down from
30 per cent in 2013.
Almost two-thirds (63 per
cent) of those who had heard
of e-cigarettes believed correctly
that they were less harmful than tobacco
cigarettes. However, there was a rise in the
proportion of young people who mistakenly
believed that e-cigarettes were just as harmful
to the user as cigarettes; between 2013 and
2016, the proportion who believed this rose
from 11 per cent to 23 per cent.
Sarah Williams, ASH director of policy, said:
‘Although more young people are trying electronic
cigarettes and many more young people are
aware of them, this has not led to widespread
regular use or an increase in smoking.’
ASH calls for funding boost to support
more stop smoking media campaigns
More funding is essential to boost stop smoking
media campaigns, according to health charity
Action on Smoking and Health (ASH).
While ASH recognises that Public Health
England holds the Stoptober stop smoking
campaign, it is concerned that government
funding for campaigns at other times of the
year has been cut.
During a recent parliamentary debate, health
minister Lord Prior of Brampton said that £4
million had been allocated for tobacco-specific
marketing activities in 2016-17, £1 million of
which was for the Stoptober campaign.
This represents a drop from the £5.3 million
allocated for 2015-16, and the amount has
declined significantly in the last six years from
almost £25 million in 2008-09.
Deborah Arnott, ASH chief executive,
said: ‘ASH strongly supports Stoptober which
provides the support and encouragement that
we know most smokers need to help them stop.
6
The Advisor | Winter 2016
‘However, we are very concerned about the
recent announcement by the health minister
in the Lords that funding for mass campaigns
like Stoptober has been cut again this year.
‘The evidence is clear, to be successful mass
media campaigns need to run throughout the
year; Stoptober alone is not enough.’
ASH said research had shown that mass
media campaigns were highly effective and
cost-effective in motivating quit attempts and
discouraging uptake of smoking.
Smoking rates in
people with serious
mental ill health
almost three times
the national average
The rate of smoking in people with serious
mental health conditions is almost three
times higher in some areas than the national
average for smoking amongst the whole
population in England.
The scale of smoking by people with mental
health issues was revealed in the Local Tobacco
Control Profiles statistics, managed by Public
Health England (PHE).
This year, for the first time, local authorities
across England can see the high rates of
smoking among people with serious mental
illness compared to the general population in
their areas.
In England as a whole, 40.5 per cent of
adults with a serious mental illness are smokers,
which is more than twice the rate of the general
population (16.9 per cent).
Rates vary across the country, and in some
local authorities, smoking rates among people
with serious mental illness are more than 50
per cent.
The Smoking and Mental Health Partnership,
a coalition of organisations, said that while
smoking in the general population has declined
steadily since the 1970s, it remains high among
those with mental health conditions. People
with mental health conditions were just as
likely as the general population to want to quit
smoking but were not getting the support they
needed, said the Partnership.
NEWS
Second-hand smoke dangers
initiative will tour deprived areas
An initiative to highlight the
dangers of second-hand smoke
within the home by setting
up pretend living rooms in
hospitals and shopping malls
for demonstrations is underway
in Scotland.
NHS Greater Glasgow and
Clyde (NHSGGC) health board’s
Smokefree Services teams
began a series of roadshows on
4 October, including visits to
deprived areas in the region.
The aim of the roadshow
events is to demonstrate the
effect that second-hand smoke has on
babies and children. Using a recreated
family living room, staff at each venue
were set to demonstrate that smoking in
one room, even with the door closed and a
window open, does not protect babies and
children from the harmful effects of secondhand smoke.
Dr Linda de Caestecker, director of public
health at NHSGGC, said: ‘Ten years on
BUTT BUSTERS
Illicit tobacco rates are rising
from the introduction of the smoking ban
in public places, attention is increasingly
focusing on the damage caused to children
and young people by second-hand smoke.
‘We want every child across Greater
Glasgow and Clyde to have the best start
in life and growing up in a smoke-free
environment is an important part of that.
We’re showing people the real damage that
second-hand smoking causes to children in
a setting they can understand.’
Parental absence during childhood linked to
smoking and drinking before teenage years
Children who grow up with a parent
missing due to death or relationship
breakdown are more than twice as likely
to smoke before reaching their teens,
according to a study published in the
Archives of Disease in Childhood.
Researchers from University College
London used data from the UK Millennium
Cohort Study, which tracks the health of
almost 19,000 children born between 2000
and 2002 in regular surveys carried out
nine months after birth, and then when the
children were 3, 5, 7 and 11 years old.
The researchers looked at complete data
for 10,940 children, more than a quarter of
whom had experienced
the loss of a parent
by the age of 7. These
children were asked
when they reached
11 whether they had
ever smoked or drunk
alcohol.
Results showed that
most children had not
smoked by the age of
11, but amongst those
255 children who had
smoked, this behaviour
was more likely among
the boys – 3.6 per cent compared with 1.9 per
cent of the girls. Drinking alcohol was more
common, with boys also more likely to have
tried it – 14.7 per cent compared with 10.6
per cent of girls.
Analysis of the data showed that children
who had experienced parental absence
before the age of 7 were more than twice
as likely to have taken up smoking and 46
per cent more likely to have started drinking
alcohol by age 11.
The researchers said: ‘Children who
experience parental absence should be
supported in early life in order to prevent
smoking and alcohol initiation.’
Official figures show that there has been a small
rise in the illicit market share of manufactured
cigarettes over the past six years at the same
time as a fall in the proportion of illicit handrolled tobacco.
Figures from HM Revenue and Customs
(HMRC) show that in 2015-16 an estimated
13 per cent of cigarettes consumed in the UK
were illicit, compared to 12 per cent in 2009-10.
The figures for hand-rolled tobacco are 32 per
cent in 2015-16 compared to 44 per cent in
2009-10.
Updated review finds no evidence
of harm from use of e-cigarettes
An updated Cochrane Review has concluded
that use of electronic cigarettes can help people
quit smoking and that there are no signs of
serious side-effects.
The first Cochrane Review, published in the
Cochrane Library in December 2014, included
13 studies and showed that e-cigarettes may be
an aid to smokers quitting.
For the updated review, the authors found
11 new studies, but only two of those were
randomised controlled trials and followed
participants for at least six months.
The studies showed that throat and mouth
irritation were the most commonly reported
side-effects in the short-to medium-term.
15 per cent drop in people seeking
help from stop smoking services
The number of people seeking the help of stop
smoking services in England has fallen for the
fourth consecutive year, according to figures
from NHS Digital.
The figures show that the number of people
setting a quit date through NHS Stop Smoking
Services in 2015-16 fell to 382,500, which was
a 15 per cent decrease on 2014-15 and a
37 per cent drop since 2005-06.
In addition, the number of people who
reported successfully quitting also fell for the
fourth consecutive year to 195,170, which
represented a decrease of 15 per cent on
2014-15, although the rate of successful
quitting remained similar at 51 per cent.
MPs call for immediate release of
new tobacco control plan
MPs on the All Party Parliamentary Group
(APPG) on Smoking and Health have called on
the government to publish its promised new
tobacco control plan without further delay.
The government committed to a new plan
after the previous one expired in December of
last year, promising to publish by summer 2016
– a deadline that has been missed.
Winter 2016 | The Advisor
7
DISPENSING INSIGHT
Through the eyes of a child
In his regular column, Michael J Walsh, a former winner of The Advisor Awards, and
a pharmacist in Warrenpoint in County Down, Northern Ireland, shares his views
and his experience of helping clients quit.
Learning to swim
I often compare quitting smoking with
learning how to swim.
They are the swimmer, we are the coaches,
and the stop smoking products are the
armbands/floats. I explain that they could just
jump in at the deep-end, but this three-pronged
approach has a much higher chance of success.
8
The Advisor | Winter 2016
We are there to give advice and
encouragement, the product is there to
provide support, but ultimately the smoker
needs to put in the work or he will sink.
Don’t pick the scab
‘If you pick the scab, it’ll never heal,’ my
mother used to warn. Regardless, I would
happily tug away at my scrapes and grazes,
the stinging of the lifting crust as it
revealed the puckered pink flesh below.
I use this analogy to reinforce the
‘not one puff’ rule. I explain that
each time they slip they hit the
reset button and have to start
all over again. The learnt
ability to smoke will always
be there, but if left alone, it
will scab over and eventually
fade to the point where it is
barely noticeable.
Playing the piano
A lapsed piano player, who hasn’t played
since childhood, will still pick it up again
much quicker than someone who has never
played before. Even though they might not
have played for decades, the brain soon
remembers the skill they learnt as a child.
Nonetheless, while they find it easier
than a complete novice, it still takes effort
and determination to relearn how to play.
The same principle applies to lapsed smokers,
it takes effort to relearn how to smoke.
Quitters who fall off the wagon will find
the first cigarette to be a disappointment.
They will have fantasied about how satisfying
it is going to be, but ultimately find that it
tastes disgusting and makes their head spin.
The second one won’t be all that enjoyable
either, but by the third they will be sucking it
down like they never quit.
I ask wavering quitters to imagine ‘if I could
give you a time machine which allowed you to
go back to when you were a teenager, and you
are just about to take your first puff….what
would they say to that fifteen year old kid?
That is what you need to say to yourself now,
because just like the piano player, the skill will
return quickly, but it will still involve effort. It
Photo: Conrad Madden
I
’ll never forget my daughter’s face the
first time she ever tasted ice-cream.
Immediately, she started to beam and
adopted a vice-like grip around the spoon.
There was no way that we were going to take
it away from her!
Most vices start off as an instant attraction,
but smoking is different. Smoking is a learned
behaviour, it is not a natural thing to do.
Nobody finds their first cigarette pleasurable,
they have to struggle against nausea and
light-headiness until they finally teach their
bodies to accept the poison.
Over time, however, smokers not only
learn how to overcome the body’s physical
repulsion, they learn to crave it. It becomes
ingrained in every fibre of their being, both
physically and psychologically. It dictates
their day, regulates their mood, and becomes
an inseparable part of their personality.
What the smoker doesn’t understand is
that it is not the cigarette that they enjoy,
but the relief from the cravings. (Alan Carr
famously compared it to someone wearing
tight shoes because they enjoyed the relief
of taking them off). In other words, smokers
only smoke so that they can feel like a nonsmoker! It is only by smoking they are able to
relieve the cravings and get back to feeling
like a normal person. Since people generally
start to smoke when they are young, most
smokers haven’t felt normal since childhood.
For that reason, childhood is a recurring
theme in my clinic. Time and time again I hear
smokers wishing that they could turn back
time, if they could only tell that foolish kid not
to start smoking in the first place. As a result
I find it useful to draw parallels with other
childhood experiences so that they utilise the
same skills when overcoming smoking.
Here are some of my favourites:
takes effort to relearn how to smoke.’
The old adage of you can’t put an old head
on young shoulders is never truer than when
referring to smoking.
The tragedy is that I see the results of
that youthful folly coming through the door
of the pharmacy on an hourly basis. People
who have worked hard all their lives, have
reared the kids, have finally paid off the
mortgage, only to spend their autumn years
in absolute misery because of one mistake
they made as a kid.
If we can help even one person to avoid
that fate, then that is a good day’s work.
THE ADVISOR AWARDS 2016
The Advisor Awards 2016
The Advisor Awards recognise the teams which excel in stop smoking support. Mark Gould looks at what
set this year’s winner and runners up apart from the other services.
T
he entries for this year’s Advisor Awards
have demonstrated a real capacity to
look beyond the four walls of their own
organisations to engage with hard-to-reach
groups. Winners Smokefree West Sussex
had the novel idea of partnering with local
mini-cab firms to target male Asian smokers.
Their mobile unit also enabled the service
to team up with NHS, fire service and local
government partners, including a highly
popular event with trading standards officers,
who brought along Scamp the spaniel who
sniffs out illicit tobacco on licensing raids.
Judge Dr Alex Bobak, The Advisor’s GP
advisor, said; ‘I absolutely loved the fact that
they are trying to attract the whole range
of hard-to-reach clients and were extremely
flexible in the way they went about it. And
they are baulking national trends in terms
of increased footfall. They were particularly
clever in the way that they targeted taxi
drivers, a group with high levels of smoking,
catching them when they were in the office.’
He also stressed that the same model
could be replicated across the country. ‘Get in
touch with your local taxi companies to see if
they are up for it,’ he advises.
Dr Bobak also praised runners-up
Warwickshire Stop Smoking In Pregnancy
Service for allowing expectant mothers and
midwives to shape a service that is ‘user
and deliverer friendly’. And he said second
runner up Help2change Shropshire, who
set up a telephone and text service to offer
extra support to pregnant women and their
families, should be commended for delivering
flexibility and innovation ‘with a lot of hard
work and no extra funding’.
The judges, who also included Jo
Glasscock, the team leader of last year’s
winners Gloucestershire NHS Stop Smoking
Services, and Fiona Dobbie from the UK
1
Centre for Tobacco and Alcohol Studies at
Stirling University, were also keen to praise
other entries that didn’t make the top three.
NHS Kent Stop Smoking was praised
for its work in prisons and partnering with
veterinary surgeries to raise awareness of the
harmful effects of second-hand smoke on
pets, and informing owners of how they can
get in touch for advice on quitting.
All three judges felt Quit4Life in
Hampshire deserved special mention for
their project with hostels targeting homeless
people, one of the hardest groups to access,
and which also considered weight and
alcohol issues.
And Yorkshire Smokefree Sheffield got a
pat on the back for it ingenious psychology,
playing on the concerns of image conscious
teenagers, it developed a factsheet for local
schools explaining how smoking can damage
their looks.
2
3
5
4
1. Help2Change Shropshire (left to right):
Allison Ball, Emma Peace, Claire Harrison,
Claire Sweeney and Pat Thomas
2. Becca Ellis (right) from Smokefree West Sussex,
Stuart Phillips from BWY Canine (specialist search dogs)
and Scamp the dog
3. Dawn Powers (right) from Warwickshire Stop
Smoking in Pregnancy Service, Trish Stringfellow, who
quit smoking when she was pregnant, and her son Luke
4. Yorkshire Smokefree Sheffield (back row, left to
right): Helen Bennett and Jackie Towers; (front row, left
to right): Andrea Bargh, Maggie Milne and Lynda Kay
5. Kathy Beel (back row, second from right) from NHS
Kent Stop Smoking Service and the Kent Trading
Standards team
Winter 2016 | The Advisor
9
THE ADVISOR AWARDS 2016
Winners – Smokefree West Sussex
A
lthough there has been a national
decline in people accessing Stop
Smoking Services, this year’s winner,
Smokefree West Sussex, has over-achieved
against targets set for the service, increasing
the number of four-week quitters by an
impressive 56 per cent, from 589 in 2014/15
to 920 this year.
The team has achieved such impressive
results by working in partnership with
the NHS, the local authority and the fire
service, developing innovative approaches to
contacting hard-to-reach groups and targeting
high prevalence areas of the county.
The service’s mobile unit has been out and
about delivering interventions to smokers in
a variety of locations, including town centres
and industrial estates, capturing smokers who
would not normally access conventional clinics.
The mobile unit has enabled the service to
support events run by other NHS partners,
the local fire service and notably local trading
standards officers, who brought along Scamp
the spaniel, one of their tobacco ‘sniffer dogs’,
to promote awareness surrounding illicit
10
The Advisor | Winter 2016
tobacco and under-age sales.
The team has also focused on interventions
with the black and minority ethnic
population, including one scheme focused
on local mini-cab offices to target male south
Asian smokers.
Clinics were held on the days when drivers
picked up their worksheets and paid the
weekly rent. The controller sent out radio
messages to drivers letting them know
when the advisor would be around and sent
text messages to the drivers’ work phones
as a reminder. The advisor was specially
selected as an Urdu-speaking Muslim man to
maximise impact and understanding.
This project is expanding into other local
businesses and has successfully achieved
108 four-week quitters in 2015/16, which
is a fantastic achievement in a hard-to-reach
client group which the service had been
trying to engage with for a long time.
The team has focused on offering tailormade programmes in a variety of settings,
ranging from hospitals to community venues,
and are always looking at ways to improve
Smokefree West Sussex (back row standing, left
to right): Gus Ferguson, Shohidul Islam,
Angela Mariner, Jane Holden, Glen Thorne,
Lesley Berry, David Etter, Caroline Staddon,
Beccy Cooper, Heather Clayton, Emma Harmes
and Rebecca Robb; (front row kneeling, left to
right): Becky Bunyan, Becca Ellis, Sam Wright
and Damian Fearns
service delivery and meet the needs of
individuals wanting to stop smoking.
It has set up an effective referral pathway
where clients are contacted within 48 hours
of referral and an appointment offered within
a two-week timeframe.
All advisors will see clients for as long as
they need to be seen and will offer one-to-one
or group appointments and home visits for
those can’t attend a community venue.
Jo Glasscock praised the team for its
partnership working and ‘great engagement’
with target groups, and Fiona Dobbie was
impressed with its ‘innovative approaches
to engaging with hard-to-reach groups’ and
‘good quit rates’.
THE ADVISOR AWARDS 2016
Runner -up
Warwickshire Stop Smoking in Pregnancy Service
W
hen figures revealed that some
12 per cent of mothers-to-be were
still smoking at time of delivery,
Warwickshire Stop Smoking in Pregnancy
Service asked midwives how they could help
ensure all women were CO tested at booking
in line with NICE guidelines.
Midwives said they were worried about
the time it took to do the test, what to say to
clients about the result, and how to construct
a simple, quick and effective way to explain
to women what the risks were before referral.
The team developed a schedule of midwife
training in small groups over a number of
days, sharing knowledge about the nature
of addiction and how to deliver a brief
intervention, and increasing awareness of
stop smoking support available locally.
Midwives were issued with easier to use CO
monitors and local advisors made themselves
available for individual support as needed.
Since then the CO test rate has risen from
69 per cent in 2015 to 79 per cent this year
and is still rising.
The midwives also
wanted a more visual
tool, that didn’t entirely
focus on the CO reading,
that would help them
to discuss smoking in
pregnancy. The team came
up with a poster, now
used across the county’s
maternity units and
children’s centres, with
simple graphics designed Warwickshire Stop Smoking in Pregnancy Service team (left to right):
Lynne Lewis, Annette Lloyd, Bev Avis-Dakin, Dawn Powers, Debbie Hammond
to get the message about and Kelly-Ann Bullingham
the risks of smoking in
pregnancy across and give midwives more
Refer), and included guidance on what to say
confidence in discussing them.
when a woman had her CO test result. Fiona
Dobbie commented that it was ‘nice to see
Midwives also received diary covers and
specific engagement with midwives’.
pens with the team’s Quit4Baby logo and
Jo Glasscock said she ‘loved the poster’,
the local free stop smoking service helpline
for urgent referrals or queries. The diary cover and that the team showed ‘great insight’
in partnering with midwives to increase
contained a mini CO chart with a quick and
easy to remember acronym: TAR (Test, Ask,
CO test rates.
Commended – Help2Change Shropshire
those who were attending face-toface sessions.
As a result, the number of
pregnant women who quit
smoking at four weeks increased
by 35 per cent, from 71 in
2014/15 to 96 in 2015/16.
This personalised support
meant that advisors could
discuss setting a quit date,
habits, behaviour change, risks of
smoking in pregnancy, addiction,
withdrawal, treatments and
Help 2 Change Shropshire (left to right): Emma Peace, Claire Sweeney, queries about e-cigarettes.
Some of the women talked
Claire Harrison and Helen Mulliner
about coping with stressful times,
he Help2Change team already
and the advisors were able to talk about
offered flexible support for pregnant
finding other ways of dealing with stress,
women, including home visits from
and point out that once free of the addiction,
early morning and into the evening, and
stress and anxiety should reduce. The team
appointments at GP practice, pharmacy and
also offered help and advice to family
community venues.
members.
Last year the team introduced a telephone
With no extra funding the team, led by
and text service for women who struggled
pregnancy advisor Claire Harrison, pooled
to go to venues, or didn’t want face-to-face
time, resources and skills and shared the
extra workload.
support, and also provided extra support to
T
The team said that by ‘identifying gaps and
thinking a little bit differently’, they were able
to make an important impact by helping to
support more pregnant women to quit and
stay quit.
Of those who set a quit date the quit rate
was 52 per cent. More importantly, although
pregnant women are thought of as a hard-toreach group, 57 per cent of pregnant women
smokers set a quit date and around a third
achieved four weeks quit. This compares
well with targets for the general smoking
population, where the ambition is for stop
smoking services to reach 5 per cent of the
smoking population.
Jo Glasscock praised the good quit rate
‘2 per cent above national average for pregnant
smokers’ and the flexibility of the scheme.
‘Having 57 per cent of all pregnant smokers
setting a quit date is fantastic,‘ she said.
Fiona Dobbie was ‘impressed with their
commitment to help this priority group
without additional funding’ and said
Help2Change would have earned her
winning vote if the presentation included
some client feedback.
Winter 2016 | The Advisor
11
Block
nicotine
to help
smokers quit
sucessfully
Prescribing information:
CHAMPIX® Film-Coated Tablets (varenicline tartrate)
ABBREVIATED PRESCRIBING INFORMATION – UK
(See Champix Summary of Product Characteristics for full Prescribing Information). Please refer to the SmPC before
prescribing CHAMPIX 0.5 mg and 1 mg. Presentation: White, capsular-shaped, biconvex tablets debossed with “Pfizer” on
one side and “CHX 0.5” on the other side and light blue, capsular-shaped, biconvex tablets debossed with “Pfizer” on one
side and “CHX 1.0” on the other side. Indications: Champix is indicated for smoking cessation in adults. Dosage: The
recommended dose is 1 mg varenicline twice daily following a 1-week titration as follows: Days 1-3: 0.5 mg once daily,
Days 4-7: 0.5 mg twice daily and Day 8 – End of treatment: 1 mg twice daily. The patient should set a date to stop
smoking. Dosing should usually start 1-2 weeks before this date. Patients who are not willing or able to set the target quit
date within 1-2 weeks, could be offered to start treatment and then choose their own quit date within 5 weeks. Patients
should be treated with Champix for 12 weeks. For patients who have successfully stopped smoking at the end of 12
weeks, an additional course of 12 weeks treatment at 1 mg twice daily may be considered for the maintenance of
abstinence. A gradual approach to quitting smoking with Champix should be considered for patients who are not able or
willing to quit abruptly. Patients should reduce smoking during the first 12 weeks of treatment and quit by the end of that
treatment period. Patients should then continue taking Champix for an additional 12 weeks for a total of 24 weeks of
treatment. Patients who are motivated to quit and who did not succeed in stopping smoking during prior Champix therapy,
or who relapsed after treatment, may benefit from another quit attempt with Champix. Patients who cannot tolerate
adverse effects may have the dose lowered temporarily or permanently to 0.5 mg twice daily. Following the end of
treatment, dose tapering may be considered in patients with a high risk of relapse. Renal impairment; Mild to moderate
renal impairment: No dosage adjustment is necessary. Patients with moderate renal impairment who experience
intolerable adverse events: Dosing may be reduced to 1 mg once daily. Severe renal impairment: 1 mg once daily is
recommended. Dosing should begin at 0.5 mg once daily for the first 3 days then increased to 1 mg once daily. End stage
renal disease: Treatment is not recommended. Hepatic impairment and elderly patients; No dosage adjustment is
necessary. Paediatric patients; Not recommended in patients below the age of 18 years. Contraindications:
Hypersensitivity to the active substance or to any of the excipients. Warnings and precautions: Effect of smoking
cessation; Stopping smoking may alter the pharmacokinetics or pharmacodynamics of some medicinal products, for which
dosage adjustment may be necessary (examples include theophylline, warfarin and insulin). Changes in behaviour or
thinking, anxiety, psychosis, mood swings, aggressive behaviour, depression, suicidal ideation and behaviour and suicide
attempts have been reported in patients attempting to quit smoking with Champix in the post-marketing experience. A
large randomised, double-blind, active and placebo-controlled study was conducted to compare the risk of serious
neuropsychiatric events in patients with and without a history of psychiatric disorder treated for smoking cessation with
varenicline, bupropion, nicotine replacement therapy patch (NRT) or placebo. The primary safety endpoint was a composite
of neuropsychiatric adverse events that have been reported in post-marketing experience. The use of varenicline in
patients with or without a history of psychiatric disorder was not associated with an increased risk of serious
neuropsychiatric adverse events in the composite primary endpoint compared with placebo. Depressed mood, rarely
including suicidal ideation and suicide attempt, may be a symptom of nicotine withdrawal. Clinicians should be aware of
the possible emergence of serious neuropsychiatric symptoms in patients attempting to quit smoking with or without
treatment. If serious neuropsychiatric symptoms occur whilst on varenicline treatment, patients should discontinue
varenicline immediately and contact a healthcare professional for re-evaluation of treatment. Smoking cessation, with or
without pharmacotherapy, has been associated with exacerbation of underlying psychiatric illness (e.g. depression).
Champix smoking cessation studies have provided data in patients with a history of psychiatric disorders. In a smoking
cessation clinical trial, neuropsychiatric adverse events were reported more frequently in patients with a history of
psychiatric disorders compared to those without a history of psychiatric disorders, regardless of treatment. Care should be
taken with patients with a history of psychiatric illness and patients should be advised accordingly. Patients taking
Champix should be instructed to notify their doctor of new or worsening cardiovascular symptoms and to seek immediate
To find out more about this new study, use this link to access your free copy:
STOP AND THINK AGAIN
Changing perspectives with CHAMPIX®
(varenicline tartrate) in smoking cessation.
New study, New data, New perspective
EAGLES: The largest comparative randomised controlled trial of
approved smoking cessation medications is now published.1
lNo
increased risk of neuropsychiatric adverse events with
CHAMPIX® vs. placebo in smokers with or without a history of
psychiatric disorder.1
abstinence rates with CHAMPIX®
vs. bupropion, NRT patches and placebo.1
lSuperior
New start.
medical attention if they experience signs and symptoms of myocardial infarction or stroke. In clinical trials and postmarketing experience there have been reports of seizures in patients with or without a history of seizures, treated with
Champix. Champix should be used cautiously in patients with a history of seizures or other conditions that potentially
lower the seizure threshold. At the end of treatment, discontinuation of Champix was associated with an increase in
irritability, urge to smoke, depression, and/or insomnia in up to 3% of patients, therefore dose tapering may be considered.
There have been post-marketing reports of hypersensitivity reactions including angioedema and reports of rare but
severe cutaneous reactions, including Stevens-Johnson Syndrome and Erythema Multiforme in patients using varenicline.
Patients experiencing these symptoms should discontinue treatment with varenicline and contact a health care provider
immediately. Fertility, pregnancy and lactation: Champix should not be used during pregnancy. Women of child bearing
potential should avoid becoming pregnant during treatment with Champix. It is unknown whether varenicline is excreted
in human breast milk. Champix should only be prescribed to breast feeding mothers when the benefit outweighs the risk.
There are no clinical data on the effects of varenicline on fertility. Non-clinical data revealed no hazard for humans based
on standard male and female fertility studies in the rat. Driving and operating machinery: Champix may have minor or
moderate influence on the ability to drive and use machines. Champix may cause dizziness and somnolence and therefore
may influence the ability to drive and use machines. Patients are advised not to drive, operate complex machinery or
engage in other potentially hazardous activities until it is known whether this medicinal product affects their ability to
perform these activities. Side-Effects: Very commonly reported side effects were nasopharyngitis, abnormal dreams,
insomnia, headache and nausea. Commonly reported side-effects were bronchitis, sinusitis, weight increased, decreased
appetite, increased appetite, somnolence, dizziness, dysgeusia, dyspnoea, cough, gastrooesophageal reflux disease,
vomiting, constipation, diarrhoea, abdominal distension, abdominal pain, toothache, dyspepsia, flatulence, dry mouth,
rash, pruritis, arthralgia, myalgia, back pain, chest pain, fatigue and abnormal liver function tests. Other side effects were,
diabetes mellitus, suicidal ideation, seizures, cerebrovascular accident, angina pectoris, atrial fibrillation, electrocardiogram
ST segment depression, myocardial infarction, haematemesis, haematochezia, Stevens Johnson Syndrome, angioedema
NEW 4-week
initiation pack
designed to
improve compliance
and chances of
quitting2,3
and decreased platelet count. For full list of side effects see SmPC. Overdose: Standard supportive measures to be
adopted as required. Varenicline has been shown to be dialyzed in patients with end stage renal disease, however, there
is no experience in dialysis following overdose. Legal category: POM. Basic NHS cost: Pack of 25 11 x 0.5 mg and 14 x
1mg tablets Card (EU/1/06/360/014) £27.30 Pack of 28 1mg tablets Card (EU/1/06/360/015) £27.30 Pack of 56 0.5 mg
tablets HDPE Bottle (EU/1/06/360/001) £54.60 Pack of 56 1mg tablets Card (EU/1/06/360/016) £54.60 Pack of 53 11
x 0.5 mg and 42 x 1mg tablets Card (EU/1/06/360/023) £54.60 Not all pack sizes may be marketed / marketed at launch
Marketing Authorisation Holder: Pfizer Limited, Ramsgate Road, Sandwich, Kent, CT13 9NJ, United Kingdom. Further
information on request: Pfizer Limited, Walton Oaks, Dorking Road, Tadworth, Surrey KT20 7NS. Last revised: 06/2016.
Adverse events should be reported.
Reporting forms and information can be found at
www.mhra.gov.uk/yellowcard.
Adverse events should also be reported to
Pfizer Medical Information on 01304 616161
Ref: CI 20_0.
References:
1. Anthenelli RM, et al. Lancet 2016. Vol 387, no. 10037, p2507-2520
2. Blak BT et al. Curr Med Res Opin 2010;26:(4):861-870
3. Pfizer, Data on file.
Date of preparation: November 2016 PP-CHM-GBR-0510 ©Pfizer 2016
nicotine-free quit
https://eorder.sheridan.com/3_0/app/orders/5803/article.php#2/z
CLINICAL FOCUS
Operation quit
While denying smokers access to routine surgical procedures may be contrary to guidelines, there are very good reasons why
smokers should be encouraged to quit, Jo Carlowe reports.
E
arlier this year, the Royal College of
Surgeons published a report revealing
that one in three clinical commissioning
groups (CCGs) in England were denying
smokers and obese patients the right to
routine surgical procedures, including hip and
knee replacements.
The CCGs were demanding that these
patients made lifestyle changes in order to
be eligible for surgery. Twelve per cent of
CCGs were demanding that smokers quit
before they could access routine surgery,
contravening national clinical guidance.
The ethics around personal responsibility
and health rationing are complex.
Nonetheless, it is common practice for
smokers booked in for a surgical procedure
to be encouraged to abstain in the weeks
preceding surgery. And there is good clinical
evidence as to why this makes sense.
14
The Advisor | Winter 2016
A raft of studies shows smokers to be at
a far higher risk for serious complications
during and after surgery than their smokefree peers. In particular, it is accepted that
wounds following surgery will take longer to
heal if you smoke, and that your chance of
infection will be higher.
In the weeks before an operation, smokers
booked in for a surgical procedure will be
encouraged to abstain from their habit. The
Royal College of Anaesthetists suggests
quitting two months prior to surgery
provides the most benefit. For smokers who
find this too hard to achieve, then a few
weeks of abstinence before surgery is still
recommended, and certainly the patient
should not smoke on the day of an operation.
The time around surgery is considered
‘a teachable moment’ by experts, and
temporary abstinence before surgery can
lead to a permanent quit, especially if the
person is supported by referral to NHS Stop
Smoking Services.
While other well-documented health
problems associated with smoking can seem
remote to the patient and ‘something that
might happen a long way off in the future’,
for anyone about to go under the knife, the
dangerousness of their habit will be brought
to the fore.
Postoperative mortality and morbidity in
smokers is substantial, and the evidence that
smoking will hinder wound repair is compelling.
Poor wound healing
Work spanning many decades, much
of it contained within the pages of the
journals Anaesthesiology, and Clinical
Anaesthesiology, shows that, compared to
non-smokers, smokers are more likely to
CLINICAL FOCUS
experience complications in tissue healing,
including infections and dehiscence (where
the scar splits), and an increased risk of
anastomotic leakage (leakage from the gut
after colorectal surgery).
Probably the largest and most cited study
is the one carried out by surgeon Lars Tue
Sørensen, of Bispebjerg Hospital, Denmark.
Published in the Archives of Surgery in 2012,
the author compared smokers and nonsmokers in 140 cohort studies, a total of
over 479,000 patients. Smokers were found
to have a higher incidence of infectious
and non-infectious healing complications
after surgery compared to non-smokers
‘across all surgical specialities’. For example,
wound necrosis after mastectomy was four
times more frequent in smokers, while in
orthopaedic and reconstructive surgery all
major studies found surgical site infection to
be more frequent in smokers.
In the same year, a study published in
the Journal of Bone and Joint Surgery listed
smoking as the ‘most important factor’ for the
development of wound-related complications
in elective cases.
The role of oxygen
The reasons cigarettes are detrimental to
wound healing are numerous, but it’s the way
tobacco smoke deprives the tissues of oxygen
that is most striking.
By allowing carbon monoxide to infiltrate
the bloodstream the cells are deprived of their
vital oxygen supply, a problem exacerbated
by the fact that smoking also narrows the
blood vessels responsible for transporting
blood and oxygen throughout the body.
Oxygen is essential for the repair and
Key facts
ound necrosis after mastectomy
W
is four times more frequent in
smokers than non-smokers
n Quitting prior to surgery reduces
wound-related complications
n Perioperative smoking cessation
decreases wound healing time
n Evidence suggest quitting two
months prior to surgery offers the
optimum benefit
n Studies suggest that smokers
have from two to 10 times the
risk of wound problems and nonunion of fractures after surgery
n
building of cells, making it critical for the
redevelopment of tissue and thus wound
healing. Indeed, smokers often need a higher
dose of anaesthesia than non-smokers, and
are more likely to need oxygen therapy due to
decreased blood oxygenation.
In addition, tobacco smoke causes
changes to the immune cells, including
pro- and anti-inflammatory cytokines, white
blood cells, and immunoglobulins, thereby
compromising immunity and increasing the
risk of infection post-surgery.
‘Quitting at least four
weeks before surgery
gives time for the body
to recover from some of
the short-term effects of
smoking, carbon monoxide
binding being one of them’
Professor Britton
John Britton, professor of epidemiology,
consultant in respiratory medicine and chair
of the Royal College of Physician’s Tobacco
Advisory Group, sums it up: ‘Tobacco smoke
contains a wide range of toxins that damage
tissues – from individual cells to structures
such as blood vessels – and also increase blood
coagulability. Carbon monoxide reduces the
amount of oxygen that can be carried in the
blood. All of these things contribute.’
Impact of quitting
Although Professor Britton says quitting will
reduce the risk, there is some evidence that
former smokers have a lifetime higher risk of
healing complications compared with patients
who have never smoked. This was the finding
from the Sørensen study. However, Sørensen
added the caveat that more studies are
needed to clarify the risk of former smokers for
postoperative healing complications.
Despite this, there are still plenty of reasons
why smokers should be encouraged to ditch
cigarettes, particularly in the weeks leading
up to surgery.
‘Quitting at least four weeks before surgery
gives time for the body to recover from some
of the short-term effects of smoking, carbon
monoxide binding being one of them,’ says
Professor Britton.
Indeed, the body is able to recover from
many tobacco induced problems within a
reasonable time period. For example, within
24-48 hours, the body can recover from
increases in blood pressure, heart rate and
peripheral vasoconstriction, conditions which
all lead to an increased demand for oxygen.
The body can also right itself within
eight to 24 hours from the formation of
carboxyhaemoglobin caused by cigarette
smoking, responsible for the deprivation in
oxygen delivery to the tissues, and its storage
in the muscles.
Smoking also causes hypersecretion of
mucus and the narrowing of the small
airways. Again, recovery can be achieved
between 12 and 72 hours.
Changes to the range of immune cell
function, leading to decreased immunity,
takes longer, with recovery taking between
one to two months.
There is also research to suggest that
smokers may have more pain after surgery
than those who refrain. Chemicals in cigarette
smoke may increase inflammation and
interfere with the way the brain interprets
pain signals. As a result smokers may find
they have pain long after their wound has
started to heal.
The above complications help illustrate
the importance of abstinence, even if only
temporary, in the weeks leading to surgery.
The benefits of perioperative smoking
cessation is backed up by research, reducing
both wound complications and decreasing
the time it takes for wounds to heal.
A 2002 study found that smokers who
participated in stop smoking interventions
had a significantly reduced incidence of
wound-related complications (5 per cent
versus 31 per cent). More recently, the 2012
study, published in Archives of Surgery,
found that perioperative smoking cessation
helped to reduce surgical site infections. And
research published in the American Journal
of Medicine, in 2011, noted a relative risk
reduction of 41 per cent for prevention of all
postoperative complications, with each week
of cessation increasing the magnitude of
effect by 19 per cent.
So while it may not be accepted NHS policy
to deny smokers their right to surgery, and
while Miss Clare Marx, president of the Royal
College of Surgeons, has made it clear that
none of the surgical associations support
‘mandatory bans for routine surgery on
the basis of whether patients smoke or are
overweight’, it is nonetheless within patients’
own interest to stub out their cigarettes,
before going under the knife.
Winter 2016 | The Advisor
15
UNRAVELLED
Old dog, successful quit
Older smokers are rarely targeted for quit attempts because there are perceptions that
this group are entrenched smokers who have few other pleasures and that the damage
to their health has already been done. But in fact, Caroline White learns, this group is
well worth targeting, because older smokers have much to gain from quitting and are
often more motivated and successful at quitting than other groups.
T
he paradox of the ‘older’ smoker –
variably defined as those in their mid50s to their mid-80s – is that they tend
to smoke more heavily than younger nicotine
addicts, yet seem to be more successful at
stubbing out their habit.
NHS Digital data on the use of stop
smoking services in England, issued earlier
this year, show that in 2014 well over half (57
per cent) of the over 60s stuck to their pledge
to quit, compared with around four out of 10
(43 per cent) of the under 18s and 52 per
cent of 45-59 year olds.
And the latest lifestyle survey figures from
the Office of National Statistics (ONS) show
that the proportion of over 60s who classified
16
The Advisor | Winter 2016
themselves as former smokers reached 75 per
cent in 2014, up from 39 per cent in 1974.
The equivalent figure for 16-24 year olds was
20 per cent, up from 13 per cent.
Motivational factors
A study of smoking patterns among the over
65s, published in BMC Family Practice last
year, points out that the quit motivations
of older adults ‘differ substantially’ from
those of their younger counterparts, ‘being
intrinsically connected to specific life
experiences,’ and shaped by their particular
social and cultural circumstances.
Sarah Lewis, professor of medical statistics
at the University of Nottingham, and
co-author of preliminary research looking
at motivational factors influencing older
smokers, thinks that the triggers are similar
across all age bands.
‘But what’s needed to get [older smokers]
to [quit] is slightly different, because they are
at different stages of their lives,’ she says. ‘For
example, I know of older smokers citing the
arrival of grandchildren and wanting to protect
them and see them grow up as the trigger.’
Paul Aveyard, a GP and professor of
behavioural medicine at the University of
Oxford, believes the jury is still out on the
reasons behind the differing quit rates. ‘It
may be that [older smokers] have reached
a point in their life where years of smoking
have begun to take their toll,’ he suggests.
A 2012 pooled analysis of the available
evidence, published in the Archives of Internal
Medicine, indicates that there’s nothing quite
like a diagnosis of serious smoking-related
ill health, such as heart disease or cancer, to
spur people into action. That’s ‘when people
are personally confronted with the harmful
effects of smoking,’ write the authors.
But as Professor Aveyard points out: ‘The
UNRAVELLED
older people smoking cessation advisors see are
those who want to stop. But many others are
likely to be “hard core” and have no intention
of quitting within the foreseeable future.’
Dependence
The ONS figures show that older smokers
get through an average of 14.5 cigarettes
a day compared with around 10.5 among
16-34 year olds, indicating higher levels of
baseline dependence.
‘The higher this is, the lower the chances
of quitting successfully,’ explains Professor
Aveyard. ‘But there’s no hard evidence to
suggest that it’s more difficult if you have
smoked 20 a day for 50 rather than 10 years.’
But longstanding addiction can be hard
to break. ‘My dad started smoking at 14 and
only stopped when he had a leg amputated
when he was 77,’ as a direct result of his
addiction, says Allison Brisbane, head of
research information and policy development
at ASH Scotland. ‘But there isn’t a day
that goes by when he doesn’t think about
cigarettes, and if he were able to hop to the
shop to buy them, he would.’
Never too late
Professor Aveyard is about to embark on
a clinical trial to assess the impact of GP
promotion of e-cigarettes to older smokers who
just can’t relinquish their nicotine fix, or who
don’t see the point. A commonly held belief is
that the damage has already been done, with
few health gains to be made, he says.
This couldn’t be more wrong, says Ms
Brisbane. While smoking lops an average
of 10 years off life expectancy over a lifetime,
it is never too late to quit and stave off
further damage.
‘Apart from an improvement in general
health and wellbeing, quitting can reduce
the amount of medication needed. And
there’s a well-established link between
smoking and rheumatoid arthritis, and
even gains to be made in bone density and
muscle mass,’ she explains.
Research shows that smoking can also
increase the amount of insulin patients with
diabetes need to take and compromise the
effectiveness of drugs, such as warfarin,
antidepressants, and antipsychotics. It can
also increase the amount of anaesthetic
needed and worsen postoperative pain.
It’s still worth quitting even after a
diagnosis of lung cancer, she insists. ‘Smoking
interferes with chemo, radiotherapy, surgery
and wound healing, and increases the risk of
developing a second lung cancer.’
A large BMJ study on the impact of
smoking cessation on cardiovascular health
among those aged 60 plus, found that while
former smokers were still at greater risk of
heart disease and stroke than never smokers,
that risk was still lower than that of current
smokers, affording them an extra three years
of life, on average.
‘The ways to support
young people to quit
require less and less time
and more distance, but
older people have got the
time and may need more
social support’
Professor Lewis
While the size of the risk was associated
with daily cigarette tally, it nevertheless fell
continuously after quitting. An Archives of
Internal Medicine study looking at the link
between smoking and risk of premature
death, reached similar conclusions. The
benefits of stopping ‘were evident in all age
groups, including subjects 80 years and
older,’ said the researchers.
Older people often have other underlying
conditions that smoking can worsen, and
which bring them into regular contact
with healthcare professionals, providing an
opportunity to hammer home the benefits of
jettisoning tobacco from their lives.
The right support
But a recent study of more than 400 primary
care clinicians in BMC Family Practice found
that only around half the respondents knew
about the impact of smoking on prescribed
drugs and nearly a third felt it was up to
specialist staff to help older people quit
rather than them.
More than a third of the nursing staff
believed that smoking remained ‘one of the
few pleasures older people still have,’ while
nearly a quarter of all respondents didn’t feel
it appropriate to discuss smoking cessation
with terminally, or mentally ill patients, or
those with dementia.
Dr Mike Gill, a consultant geriatrician who
led a recently completed programme for the
London Clinical Senate to boost quit rates,
says that ‘paternalism is rife’, in healthcare,
but that every clinician should know the
smoking status of the patients they care for,
whatever the condition being treated.
‘If you are a smoker, you’ve got a
dependency, and the way you deal with
that is going to be similar across the board,
irrespective of age,’ he says.
‘You can’t force an older person to stop, but
you can signpost them to services and point
out the damage it is doing. You need to give
them the same options as everyone else,’ he
insists, adding that giving up smoking can be
more cost and clinically effective than dishing
out pills.
Professor John Britton, director of the UK
Centre for Tobacco and Alcohol Studies, agrees.
‘High blood pressure or diabetes would never
go untreated, but we do this all the time with
smoking, and it’s unacceptable,’ he insists. ‘All
healthcare professionals should be trained to
provide advice on how to stop smoking.’
But older smokers don’t merit special
treatment based on age. Rather, he says:
‘We should treat all smokers differently –
by intervening.’
Professor Lewis doesn’t believe they should
be treated differently either, but thinks there
are particular issues to consider. Her research
pinpointed social isolation as a hindrance for
older would-be quitters.
‘The ways to support young people to quit
require less and less time and more distance,
but older people have got the time and may
need more social support,’ she suggests. ‘I am
not saying that they don’t use social media or
go online, but they didn’t grow up using it the
way younger people do now.’
Ms Brisbane feels that the other argument
that gets missed is the cost of smoking, which
may be particularly relevant for older smokers
who have retired.
‘The Scottish government has just issued
a strategy about income maximisation
for older people, yet neglected to include
smoking, yet that is a comparatively large
proportion of expenditure,’ she laments.
‘Smoking burns money.’
And then there’s the cost to health
services of treating smoking-related disease
and its complications.
Older smokers currently make up only
around 10 per cent of all smokers, but that
is set to change as Baby Boomers age. ‘Older
smokers are not a priority group, because
smoking rates are going down, but they
will make up a larger proportion of smokers
over the next 10 to 20 years, so I think we
will see a shift in priorities,’ suggests Rachel
Murray, associate professor of health policy,
University of Nottingham.
Winter 2016 | The Advisor
17
THE CLINIC
Quit Positive
A service designed specifically for the needs of patients with mental health issues in Kent is achieving quit rates in this
challenging group similar to those attained by the general service, finds Jo Carlowe.
S
moking rates in England have fallen to
the lowest on record, yet the prevalence
amongst people with mental illness
remains a worry.
Figures from Public Health England reveal
that in 2015 16.9 per cent of adults described
themselves as smokers, compared with 19.3
per cent in 2012, but experts say there has
been little reduction among people with
long-standing mental illness, with studies
suggesting rates of up to 70 per cent.
Two-year pilot
In Kent, Medway’s Tobacco Control and
Smoking Cessation Team, has launched a
scheme called ‘Quit Positive’ to try to reach
this group.
The idea took shape a few years ago when
Angela Bates, tobacco control programme
manager, was working at Medway Maritime
Hospital, and encountered patients with
18
The Advisor | Winter 2016
significant ill health who wanted to quit
smoking. When treating patients with mental
health needs, as well as physical illnesses,
it became clear they often needed ‘more
intensive support’ to quit smoking.
‘I began doing some research into smoking
cessation support for this population group
and found that due to high smoking rates,
the smoking-related morbidity and mortality
are also much higher in this group.’
For example, respiratory disease, heart
disease and cancer rates are double in
those with schizophrenia compared with the
general population.
‘Hence why it is so important to target
support here,’ says Angela.
On the back of this, Angela proposed a
two-year pilot for a specialist service to be set
up which cumulated in ‘Quit Positive’.
A Quit Positive training package
was developed, which included specific
information on smoking and mental health.
Initially this was delivered to staff from the
local NHS mental health trust and referral
pads were distributed to mental health
teams. The training was then advertised more
widely to include some Medway GPs, and
local charity organisations.
The local authority’s mental health and
social work team also now refers to Quit
Positive, and occasionally a patient gets
enrolled opportunistically having called into
the stop smoking service shop in Chatham.
Designed for needs of patients
The course has been tailor-made to meet
the needs of mental health patients, with
patients seen one-to-one. Instead of a normal
seven-week standard support model, it has
been extended to 12 weeks. The scheme
also allows for a greater amount of nicotine
replacement therapy (NRT) on prescription —
THE CLINIC
12 weeks of combination therapy as opposed
to 12 weeks of single therapy.
Quit Positive also includes bespoke training
for mental health staff, and strong links and
communication between advisors and each
patient’s mental health team.
Bespoke patient resources are used, such as
Quit Positive diaries, and patients are taught
relaxation and coping techniques, as well as
cognitive behaviour therapy (CBT).
A medication monitoring system is used for
patients taking psychotropic drugs, including
clozapine, olanzapine and duloxetine, as
smoking cessation can have an effect on the
metabolism of some medications.
Angela notes that many patients, despite
wanting to quit, are fearful.
‘They are concerned that they are unable
to do it and/or their mental health will
deteriorate if they do,’ she says. ‘Individuals
often need a lot of reassurance and support
to increase self-belief and motivation. For
some patients, the course and medication
options may need to be gradually introduced
and explained over more than one face-toface support session.’
The idea of trial and error often needs to
be employed. ‘A raft of different relaxation
and coping strategies need to be available so
that patients can find the ones that work best
for them,’ explains Angela.
Flexibility is key. ‘If patients feel that
their quit attempt is not going well, this
can sometimes be felt much more keenly
than it is in patients without mental health
needs. More reassurance may be needed
to explain that it is okay to try again and
that not everyone succeeds first time. Some
patients live quite chaotic lives and therefore
a great deal of flexibility and understanding
is needed. Anything from the venue to the
entire (previously agreed) quit plan may need
to be changed at the last minute.’
Positive outcomes
Lauren Alper, health improvement coordinator
(mental health), at Medway Council.
describes the work as a ‘constant learning
experience’. ‘It is so rewarding when patients
do successfully make a change to their
smoking behaviour, especially if they were
extremely apprehensive and self-doubting in
the beginning.’
Feedback from patients is generally good,
CASE STUDY
Mary*, 56, has a personality disorder. She
quit smoking via Quit Positive, having
smoked for 40 years.
‘I started smoking due to peer pressure,
then I used it to cope with stress.
My mental health condition meant
choosing to try and quit was a tough
decision to make.
I have personality disorder, anxiety and
depression and I used smoking as a way
to manage stress. My main worries when
I thought about quitting were that my
depression might get worse and I would
have nothing to help me manage my
anxiety and stress.
I regularly attend a peer support group
and one week Lauren Alper (see above)
came in and talked to us all about Quit
Positive. This was just a general chat, so
I didn’t feel anyone was trying to make
me quit smoking if I didn’t want to.
Lauren explained about the service and it
sounded good and like she understood the
challenges you might face if you have a
mental health condition. I therefore asked
the resource centre staff for a referral to
Quit Positive and the rest is history.
I managed to quit completely with the
service and have not smoked now for a
year. I found the cut-down-to-quit process
very helpful because I started by just not
smoking inside my house, and this was
seen as an achievement in itself; I had
created a smokefree home for myself.
I also liked the quit diary, breathing
exercises and the local appointments that
were tailored to my needs.
I was initially worried about how I
would manage to quit, but the course
provided so much support, new techniques
and understanding that I gradually
calmed down and took each day at a time.
I had made some attempts to quit on
my own in the past but they never lasted.
It was different this time because I felt
Lauren understood my needs and went at
my pace.
The service has made a great difference
to me. I feel healthier and can breathe
better. Money was always a big worry
for me – there were times where I had
to sell my jewellery so I had the money
for cigarettes, but since I’ve quit I have
managed to buy it all back. I’m really
proud of myself.’
*Name changed.
Angela Bates, tobacco control manager
with most commenting how much they
appreciate having a course available that
meets their specific needs.
‘Many clients have felt that these needs
have been understood and accommodated
and say it is this that has helped them in
making a change to their smoking behaviour,’
says Lauren. She says clients often go on to
recommend the course to friends.
The scheme has been very successful.
The pilot operated from November 2014 to
February 2016 and in this time 104 patients
were referred into Quit Positive.
The quit rate was 44.2 per cent, which is
comparable with the average Medway Stop
Smoking Service success rate of 47 per cent
for the same time period. An additional 23.1
per cent of Quit Positive patients managed
to cut down their smoking by more than 50
per cent, meaning 67.3 per cent of patients
accessing the service made a positive change
to their smoking behaviour.
Due to the success of the pilot, Quit
Positive is continuing.
Lauren notes that quitting tends to lead to
an increase in self-confidence. In some cases
patients have even been able to lower the
dose of medications taken for their mental
health condition and to make other positive
life changes.
‘It is a great privilege to watch this happen.’
Winter 2016 | The Advisor
19
HOW THEY DO IT IN...
Denmark
Cancer plan has smoking cessation at its
heart to create smoke-free generation
Denmark is set to tackle its unfortunate reputation for having some of the
worst cancer survival rates in Europe by focusing on smoking cessation,
reports Adrian O’Dowd.
T
he deadly impact of smoking is all
too clear for Denmark, which has one
of the worst cancer survival rates in
Western Europe.
A new drive, therefore, has been unveiled
to address the fatal grip that tobacco has
been holding over its people.
The government has recently announced a
wide-ranging cancer strategy, called Cancer
Plan IV and, with additional funds being
added to already allocated money, it will
make a total investment of 2.2 billion kr
(£260 million) between 2017 and 2020 into
tackling cancer.
The scale of the problem is undeniably
significant in the country where smoking
rates are around 18 per cent for people aged
15 and over.
A large study released at the European
Cancer Congress in Vienna last year reported
that Denmark’s cancer survival rate of 50.9
per cent was near the bottom of all western
European countries and far below the level
of its Nordic neighbours: Sweden (64.7 per
cent), Finland (61.4 per cent), Iceland (61.2
per cent) and Norway (58.6 per cent).
There are around 35,400 newly diagnosed
cancer cases every year in Denmark and
15,400 cancer deaths, with lung cancer being
the second most common form of cancer in
men and women after prostate and breast
cancer respectively.
20
The Advisor | Winter 2016
According to the World Cancer Research
Fund International, Denmark is the country
that has the highest cancer rate (for all
cancers), with 338 people per 100,000
people diagnosed in 2012 (the UK’s figure
was 273 people per 100,000).
The Danish government says there has
been significant progress in cancer treatment
in its country over the past 10-15 years, with
decreasing mortality and a better quality
of treatment due to previous targeted
investments under its Cancer Plans I, II and III.
Educational institutions
Cancer Plan IV aims to increase cancer
survival in Denmark so that it is on a par with
the best of Denmark’s neighbouring Nordic
countries by 2025.
The main themes of the government’s
cancer plan are: Denmark to have its first
smoke-free generation in 2030; more people
surviving cancer due to increased capacity
in hospitals to allow more patients to be
investigated and treated; and greater focus
on patient involvement.
One way of achieving the objective
for Denmark to have the first smoke-free
generation by 2030 will be to tighten
smoking laws, including new smoking
restrictions at educational institutions.
The present legislation forbids smoking
on school premises at vocational education
and training and general upper secondary
education establishments, where the majority
of students are younger than 18 years old.
However, smoking is allowed in a defined
smoking area on schoolgrounds at schools
and colleges where the majority of students
are 18 years or older.
The proposed changes recommend that all
students younger than 18 attending education
should have smoke-free premises regardless
of the majority age group there, and that the
pupils are not allowed to leave school grounds
to smoke at any time during school hours.
Health minister Sophie Løhde said: ‘Too
many children and young people are starting
to smoke. We must do something about this.
If we can reach the goal that none of the
children born today are smoking in 2030,
then we will have come a long way in relation
to preventing new cases of cancer.
‘Therefore, I hope that there will be support
to implement the initiatives in the cancer
plan, which will send a clear signal that
children and smoking do not mix, and prevent
young people from becoming smokers.’
In addition, the government plans to enter
into partnerships with business so that stores
do not sell tobacco to minors.
Professional
recommendations
Prior to the strategy launch, the Danish
Health Authority was asked by minister Løhde
to make professional recommendations for a
renewed strategy to battle cancer. Its report
was sent to the ministry of health in July of
this year, and the resulting strategy contains
some, but not all, of its recommendations.
Nina Krogh Larsen, public health
professional at the Danish Health Authority,
says: ‘If all the recommendations in the report
from the Danish Health Authority were carried
out, we would expect a significant reduction
in smoking prevalence in all age groups.
‘The recommendations focus on smoking
HOW THEY DO IT IN...
among youth (increased tax on tobacco,
display ban, smoke-free schools, enforcement
for the minimum-age-law on purchasing
tobacco), but most of the recommendations
will also affect other groups of smokers.
‘We also recommend subsidies for smoking
cessation medicine for heavy smokers, if they
follow a smoking cessation programme.’
Some actions can be taken by the minister
on her own accord, but the government
needs a majority in Parliament to put other
steps of the plan into action, such as a law on
smoking by students in schools and colleges.
Some of the steps will be part of the Finance
Act for 2017, which is being negotiated.
Asked how ambitious the government’s
target is for a smoke-free generation by 2030,
Larsen says: ‘It is an ambitious goal, but it is
achievable. It all depends on the political will
to apply the necessary preventive measures
as suggested in the report from the Danish
Health Authority.’
The plans to change the law on smoking
by students in schools and colleges could
make a real difference, Larsen adds. ‘We
What we can learn
from them
aving an ‘end-game’ target
H
such as a ‘x’ per cent reduction in
smokers by a specific year helps
to maintain smoking cessation
efforts over a long period and
beyond the political life of the
current government
n Stopping older students from
leaving school/college premises
during official hours to smoke
outside the premises could help
dissuade them from continuing
to smoke
n
recommend that ‘smoke-free school hours’
should be implemented by law for both
primary schools and vocational education
and training and general upper secondary
education. This would make a real difference
in denormalising tobacco.
‘At present it is allowed to smoke just
outside the school premises during school
hours resulting in very overt smoking. The
focus of this proposed legislation is to protect
young people from passive smoking and
to denormalise smoking and restrict the
influence of negative role models.’
Tough enough?
The Danish Cancer Society has praised
the strategy, but it says it could and should
go further.
Niels Them Kjær, head of tobacco control
for the society, says: ‘I am pleased they
[government] have this long-term goal about
a smoke-free generation.
‘However, the minister only went half the
way and picked up the part about children.
It’s setting a long-term goal and then later
on you find a way. That’s a good idea. The
minister has proposed some methods to go
along with that. These are a step in the right
direction but for sure, they won’t be enough.’
The smoke-free school time plans would
What they can learn
from us
H
igh and continuingly rising prices
for tobacco products is a useful
deterrent for smokers
nB
an on point of sale marketing
and standardised, plain packaging
of tobacco products are useful
tools in fighting the appeal of
cigarettes to younger generations
n
make a difference, he adds, saying: ‘School
grounds are already smoke-free, but this
means that the pupils are not allowed to
leave the school grounds to smoke from the
morning until they go home in the afternoon.
‘That will make a difference because right
now, especially the older school children,
they leave the school in the break in the
middle of the day and stand outside on the
pavement smoking.’
On the subject of why Denmark’s cancer
survival rates are lower than those of its
neighbouring countries, Kjær says: ‘The
Danes are living more unhealthily than the
rest of the Nordic countries.’
Around 10,000 people a year use smoking
cessation services in the country, he estimates,
saying: ‘Denmark does well on smoking
cessation and it is available in nearly all
bigger cities and is free apart from paying for
equipment like nicotine replacement therapy.
‘One thing I would like to have in Denmark
is the UK’s prices on cigarettes. In real terms,
your cigarettes are twice the price than we
have in Denmark.’
The Danish Health Authority’s Larsen
believes smoking cessation can work well for
many people but is currently underutilised.
‘We estimate that well below 1 per cent of
smokers are using smoking cessation clinics
and quitline help in Denmark,’ she says.
‘This resonates with the general finding that
prevalence of daily smoking has remained
unchanged in the last four to five years.
‘However, local projects, where subsidies for
smoking cessation medicine for heavy smokers
is offered, have been shown to be successful.
‘In some municipalities, up to 5 per cent
of the heavy smokers attended a smoking
cessation program. Also the quit rates for
these projects are pretty good.’
The task ahead to cut smoking rates
and improve cancer survival in Denmark
is considerable, but the will to tackle the
problem is off to a promising start.
Winter 2016 | The Advisor
21
YOUR QUESTIONS ANSWERED
Your Questions Answered
by Jennifer Percival, national stop smoking trainer and RCN tobacco policy advisor.
Q
I recently had a client where
my interaction didn’t end as I’d
expected. The man had been attending
for a few weeks but hadn’t managed to
stop smoking. I queried if he was really
ready and suggested he take a break and
try again in the future. He wasn’t very
happy about this and walked out on me.
A When clients continue to smoke after their
quit date it seems natural to offer them the
option of taking a break and starting a new
attempt at a later date. Inadvertently, this
may result in some people thinking you have
made the decision for them and are cutting
them off from your support.
To avoid this outcome try asking: ‘Remind
me again, why did you want to stop
completely?’, ‘What is going on that’s making
this hard for you?’, ‘What have you already
tried to do about it?’, and ‘How would you
feel if you gave up and went back to your
previous smoking levels?’
Listening to these answers will give you
and your client a much clearer understanding
of their current situation and the challenges
they are facing.
Next, find out whether it’s the right time
for them to continue on their programme
by asking: ‘With everything you have told
me, can I ask how realistic it is for you to
be able to make some changes and stop
smoking completely?’
Handling the problem in this way, leaves
the decision-making process entirely with
your client, and the next stage and outcome
clear to you both.
Q
At my service we are getting
increasing numbers of people who
sign up to attend, come for three to four
weeks and never quite manage to quit
completely. The same people come back
every few months asking to sign up and
start again and nothing seems to work.
A When you sign someone up to your service,
check their commitment to the full programme,
go through the changes they plan to put in
place, find out what might get in their way and
help them develop a range of coping strategies.
At this stage it is vital to set clear boundaries of
what you can and cannot offer.
Explain that the stop smoking services are
set up to help clients who are committed
to quitting completely, and ask them if this
is their goal. Explain the ‘Not a single puff
Diary
17 – 20 January 2017 Tuesday – Friday
The Ultimate Stop Smoking Roadshow 2017
Stop smoking advisors are invited to join one of three free half day
workshops on the latest developments in stop smoking cessation and
nicotine addiction. The workshops, which have been initiated and
funded by Pfizer, will be held in Nottingham (17th), Leeds (18th) and
Newcastle (20th).
www.ultimatestopsmokingroadshow.co.uk
20 – 21 January 2017 Friday – Saturday
Westin Hotel, Ottawa, Canada.
International experts will share the latest concepts in clinical tobacco
treatment, programme development, and smoking cessation research.
http://ottawamodel.ottawaheart.ca/ottawa-conference/program
22
The Advisor | Winter 2016
rule’, and ask them if they are ready to make
this promise to themselves (not you). Listen
to them say out loud that they promise
themselves not to have a single puff after
their quit date. Reiterate its importance and
ask how they felt hearing themselves say this.
If a client is frequently having an ‘odd’
cigarette after their quit date, even with
‘good reasons’, remind them that if nothing
has changed on their next visit you will
be unable to continue supplying the
medication/support you’re currently offering.
If they have been down this route with
you several times before, summarise their
past history and ask what is stopping them
getting past this point. Find out what are
they hoping will be different this time, and
what makes now a good time to try again.
Although we are flexible and understand
that in the first weeks unexpected challenges
can arise, our goal is to help people achieve
an abrupt quit. From the beginning your
clients need to know you are not offering a
cut down to quit programme.
Send your questions to
[email protected]
For more diary dates go to:
www.theadvisoronline/diary-dates
8 March 2017 Wednesday
No Smoking Day
This annual awareness day has been running since 1983.
www.awarenessdays.co.uk/awareness-days-calendar/no-smokingday-2017-03-09/2017-03-08/
8-11 March 2017 Wednesday – Saturday
2017 Society for Research on Nicotine and Tobacco 23rd
Annual Meeting
Florence, Italy
The scientific programme will cover the latest research and practice
in the field of nicotine and tobacco research.
www.srnt.org/?page=Meeting
Send your diary dates to
[email protected]
BUTT ENDS
Never too young
Some children start smoking before they even reach secondary school, so stop smoking services in
Nottinghamshire have started going into primary schools to tell very young children about the dangers of
smoking, explains Helen Shields, tobacco control lead at Smokefree Life Nottinghamshire
C
hildren who
Pupils were encouraged to engage with
live with adults
the adult smokers they lived with by entering
who smoke are
a drawing competition with the theme ‘Say
more likely to take up
Yes to a Smokefree Home and Car’. On the
smoking themselves,
reverse of the drawing space of the entry
and conversations with
form, was a Smokefree Homes Pledge, which
clients accessing stop
pupils asked their parents to sign and then
smoking services along
returned to the school.
with local data collection highlighted that
The entry form was given to pupils in a
this was an issue in Nottinghamshire. After
small bag, which also contained leaflets about
discussion with primary schools in areas of
second-hand smoke, smoking in cars and quit
high smoking prevalence, Smokefree Life
tips, plus information about the stop smoking
Nottinghamshire, which is managed by
service and how to contact it. The children
Solutions4Health, launched two Smokefree
were asked to talk to their parents about what
Homes and Cars pilots in two of the schools.
they had learned and encouraged to share the
The pilot initially planned to target pupils
information packs with their parents/carers.
aged 11 years, but school staff asked for it to
A total of 335 pupils attended the
be extended to include children as young as
presentations and took home the information
seven, because they had identified
problems with this group of
children smoking and the view
was that getting the smoke-free
message across at a younger age
would be a good idea.
The stop smoking service
began by delivering 50 minute
informal presentations in school
assemblies and gave the pupils
the opportunity to ask questions
and handle ‘props’, such as a ‘tar
jar’ and ‘smoker’s lung’, which
Helen Shields gives primary school children a chance to ask questions
about the dangers of smoking and second-hand smoke
stimulated more questions.
IN SMOKING
INSPIRATION
ISSN 2043-7684
| Vol 7 Issue
packs. Data on whether the pilots have led to
referrals into the stop smoking service is not
yet available, but the important messages of
the ill-effects of second-hand smoke in homes
and cars has reached a large proportion of the
population. Stickers were given to pupils and
they were asked to place them in windows if
their home and car was smokefree.
The winners of the drawing competition
received prizes donated by local businesses
and football teams, bringing the secondhand smoke message to the attention of the
wider community.
The pilots have helped build strong
relationships with the schools involved. Staff
felt the information given was extremely
valuable and well received by pupils , and
they have requested further presentations and
invited the stop smoking service to attend
school events to engage with pupils’ parents
and carers. In the future, stop smoking sessions
for parents and carers may be held within the
schools and a Smokefree School Gates initiative
is planned, which will see the stop smoking
service support the school to write a policy
and then its outreach team engage with any
parents and carers smoking at the school gates.
If you would like to contribute
to Butt Ends contact:
[email protected]
Are you reading your own copy?
CESSATION
4
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s 2016
Year Award
Team of thesurgery
oing
The Advisor
Winners ofs smokers face when underg
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The added
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203
s and features
Denmark sets
ing news, view
For more stop
smok
grant
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Limited has provided
this publicat
distribution of
Johnson & Johnson
production and
to support the
Pfizer
Supported by
21/11/2016
11:31
The next issue, Spring 2017, is published in March 2017
16.indd 1
Winter20
AdvisorCover
Winter 2016 | The Advisor
23
THE
ULTIMATE
STOP SMOKING
ROADSHOW 2017
If you attend only one smoking cessation event in 2016,
make it The Ultimate Stop Smoking Roadshow
What will the Roadshow offer you?
• Up-to-date facts and expert opinions on smoking cessation
• Latest clinical study news
• A comprehensive examination of the challenges faced by GPs, Practice Nurses, Smoking
Cessation Advisors and Community Pharmacists when helping patients to quit
• Presentations and a panel Q&A session, led by UK smoking cessation KOLs
3 events across the UK
Nottingham
17.01.2017 The Nottingham Belfry – Q Hotel – Half-day
Newcastle
18.01.2017 Newcastle Marriott Hotel Gosforth Park – Half-day
Leeds
20.01.2017 Village Hotel Club Leeds North – Half-day
Registration and attendance
are free of charge.
Register early places are limited.
Recommended 4 CPD hours
Register today at www.ultimatestopsmokingroadshow.co.uk
Further details available on the website
This program is initiated and funded by
Pfizer and will include reference to Pfizer
medicines relevant to the agenda topics.
In association with:
Date of preparation: October 2016.
PP-CHM-GBR-0476
All meeting costs, including speaker honoraria, have been covered by Pfizer
Cogora Limited | Terms and conditions | www.cogora.com
Endorsed by: