Smoking

Epidemiology Smoking is the biggest preventable cause of disease and premature death in the world. In the UK (2022) 12.9% of people over 18 years old were found to smoke cigarettes, 11.2% of women and 14.6% of men.

There is a strong link between cigarette smoking and socioeconomic group. In 2022, 22.5% of adults in the UK in routine and manual occupations smoked compared with 8.3% in managerial and professional occupations. This makes smoking the biggest single determinant of health inequality between classes.

Action on Smoking and Health (ASH) estimated in 2019 that ‘30% of smokers in the UK had a mental health condition, and more than 40% of adults with a serious mental illness smoked’. There are numerous fallacies around quit attempts being unbeneficial or even harmful for those with mental illness. The evidence is that smokers with mental illness significantly reduce their physical as well as psychiatric morbidity after stopping smoking, and helping them to become smoke-free is not as difficult as most people think.

Harmful effects

Inhaled tobacco smoke is an extremely effective way of delivering harm to the human body. Each puff contains approximately 4,000 substances, of which about 250 are known to be toxic and 65 to be carcinogenic.

Inhalation allows these substances to avoid first pass metabolism by the liver and be distributed without dilution throughout the entire systemic circulation. This means every organ system in the body is exposed to the negative impact of smoking.

Smokers may present with various symptoms or issues including:

• Bad breath
• Hoarseness
• Erectile dysfunction
• Thirst/dry mouth
• Cough

Of the 21 clinical domains for QOF 2023/24, at least 18 of these 21 clinical conditions are either caused by or made worse by smoking. So tackling this one risk factor can greatly reduce the impact of these conditions on patients as well as GP workload.

Brief interventions

The standard accepted brief intervention on smoking as recommended by NICE is called Very Brief Advice (VBA):

• VBA was initially designed for time-pressured UK GPs.
• This advice can be delivered in less than 30 seconds, opportunistically, in almost any consultation with a smoker.
• While GPs often tell their smoking patients to quit or ask whether they want to quit, these interventions may actually reduce the likelihood of the patient accepting smoking advice as they ‘challenge the addiction’, which can trigger denial.
• VBA avoids this by substituting advice to stop with advice on how to stop. The focus is on non-judgemental signposting towards where they can get the best support and treatment when they choose to stop.
• VBA is delivered in three simple steps:
  • Firstly, establish the patient’s smoking status by asking if they smoke or are still smoking.
  • Next advise that the best way to stop is with a combination of support and treatment (without advising to stop or any questions about their smoking).
  • Lastly, offer the support and treatment that is locally available.
• The intention is that, when ready, the patient should book an appointment for a supported quit attempt either in the practice, through a local pharmacy or at a stop smoking clinic.
• The simple framework of VBA saves time within consultations whilst delivering a worthwhile intervention that may well have a greater chance of success than what you are already doing.
• For free training on how to give VBA, visit the National Centre for Smoking Cessation and Training (NCSCT) website.

Medical intervention

The combination of behavioural support and medical treatment is well established to be the most effective way to help people stop smoking and is recommended for every quit attempt.

Behavioural support and treatment work together to increase the likelihood of a successful quit attempt by up to ten times that of ‘willpower alone’.

There are four licenced treatments in the UK: nicotine replacement therapy (NRT); bupropion (Zyban); varenicline (Champix); and now cytisine (Cytisine, recently approved by the MHRA). Contradictions and cautions for each are summarised below. Note supply issues may affect availability.

Bupropion

• Contraindications: acute alcohol withdrawal; acute benzodiazepine withdrawal; bipolar disorder; CNS tumour; eating disorders; history of seizures; severe hepatic cirrhosis
• Cautions: alcohol abuse; diabetes; elderly; history head trauma; predisposition to seizures (prescribe only if benefit clearly outweighs risk)
• Avoid in pregnancy

Varenicline

• Cautions: Conditions that may lower seizure threshold; history of CVD; history of psychiatric illness; predisposition to seizures
• Avoid in pregnancy

Cytisine

• Contraindications: unstable angina; recent MI; clinically significant arrhythmias; recent stroke; pregnant or breastfeeding
• Cautions: CHD, heart failure, hypertension, pheochromocytoma, atherosclerosis and other peripheral vascular disease, gastric and duodenal ulcer, GORD, hyperthyroidism, diabetes, schizophrenia

NRT comes in various forms (patches, gum, lozenges, inhalators, oral and nasal sprays) and can deliver nicotine in a slow, medium or fast acting manner depending on the product.

There is significant misunderstanding over the safety of nicotine which often puts people off using NRT. Nicotine is in fact a relatively safe substance on a par with caffeine. A useful adage is that ‘it’s the nicotine that makes people smoke, but the smoke that kills them’.

A combination of two or more types of NRT is now the standard regime, eg, patch + a medium/fast releasing product.

Bupropion and varenicline are tablets which can be taken daily for the standard 8-12 weeks of a quit attempt.

While varenicline and cytisine have a similar mode of action, that of bupropion is different. Bupropion is a dopamine/noradrenaline reuptake inhibitor which causes elevated levels of dopamine which reduce the desire to smoke.

Varenicline and cytisine are partial agonists and blockers of α4-β2 nicotinic acetylcholine receptors in the brain. The blockade reduces the nicotine hit from smoking while the agonist effect gives a sustained low delivery of dopamine which relieves cravings and withdrawal symptoms.

Smokers taking cytisine should aim for a target quit date no later than the fifth day of taking the medication, while with bupropion and varenicline a quit date in the second week is recommended.

It is important that all smokers should have the choice of all treatments at each quit attempt. This is because treatment choice enables self-efficacy, which is key when trying to create a behavioural change. Also, if a patient doesn’t quit successfully first time, it ensures they will know there are other options available for their next attempt.

Behavioural support is not complicated but highly effective. Essentially it involves being there for the smoker to answer questions, boost motivation and monitor treatment. The Brief Support and Treatment (BST) regime has been designed for GPs to support their patients through quit attempts. It consists of four to six appointments over 8-12 weeks:

1. Pre-quit appointment
   • Congratulate and check motivation.
   • Check addiction level (time to first cigarette after waking) as this influences recommended doses of NRT.
   • List and discuss available treatments and prescribe agreed cessation treatment for first 2 weeks.
   • Agree and record quit date.
   • Gain commitment to ‘not a puff’.

2. Quit date appointment (can be same appointment as ‘pre-quit appointment’ if NRT is being used)
   • Address any concerns around medication prescribed.
   • Discuss strategies to deal with withdrawals.
   • Discuss their smoking contacts and who will be supportive and who initially to avoid.
   • Identify triggers and advise on how to avoid/manage them.

3. Follow up appointments (over 8-12 weeks)
   • These appointments are flexible and can be done remotely if that is more convenient.
   • They serve mainly to give ongoing support, motivation and opportunity to ‘check in’ with any issues which may have arisen.

4. Final visit
   • Congratulate on success (hopefully).
   • Discuss relapse prevention.
   • Advise that you are always happy to help in the future if they need it and other treatments are available if necessary.

Vaping

In 2023 4.7 million adults (9.1% of the UK population) vaped. This is an increase from 4.3 million (8.3%) in 2022 and 3.7 million (7.1%) in 2021. Of the 4.7 million in 2023, 4.4 million were ex-smokers or current smokers while 320,000 had never smoked.

Whereas cigarette smoke contains over 4,000 substances many of which are toxic or carcinogenic, e-cigarettes/vape products contain five constituents, which are glycerol, propylene glycol, flavourings, colourings and nicotine, none of which is usually associated with significant negative health effects. Also there is no combustion with vaping which means no inhalation of toxic or carcinogenic products of combustion.

Despite a high false perception of harm prevalent in the media, it is now accepted that e-cigarette vapour is at least twenty times safer than cigarette smoke. Whilst not risk free, if the choice is between smoking and vaping then vaping should definitely be advocated.

Vaping is now deemed more effective in smoking cessation than prescribed NRT. However, many people who use vapes to stop smoking successfully continue to vape long term, while those who use NRT and quit smoking successfully usually stop the NRT within three months. Also one-third of people using vapes continue to smoke and are in need of supporting advice on how to stop smoking completely, as even minimal smoking conveys significant health risk.

There is too much variety in vape delivery systems to give evidence-based advice and they are not made by pharmaceutical companies with trialled evidence behind them. Therefore orthodox treatments (NRT, bupropion, varenicline and cytisine) should be recommended by GPs as first-line, as we can have confidence in their safety and efficacy. However, if smokers prefer to vape as a way of stopping smoking, this can be recommended, in line with NICE guidance, on the principle that vaping is far less harmful than smoking and self-determination is an important factor in quit success.

Dr Alex Bobak is a GPwSI in smoking cessation in Wandsworth, South London