Key learning points

  • Smoking is the most preventable cause of death and ill health in the UK. 
  • Most people find it difficult to stop smoking and they need expert help to succeed.
  • The NHS provides a wide range of support, treatment and advice to help smokers quit.
  • Smokers are 3 times more likely to succeed using NHS help and licensed medication. 
  • While not completely risk free, switching completely to vaping is significantly less harmful than continuing to smoke.

Introduction

Smoking is the single most preventable cause of death and ill health in England and half of all smokers die prematurely because of smoking.1 Smoking disproportionately affects the poorest members of society, owing to differences in culture and lifestyle. It is one of the main reasons for health inequalities and a cause of great concern.2

Smoking has been linked to a wide range of serious illness such as cancer, heart disease, stroke, diabetes, and chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis.3

Most people start using tobacco as children and despite frequent attempts to quit, remain lifelong smokers because of the highly addictive nature of nicotine.4 Smoking is a long-term condition, classified by the Royal College of Physicians as a ‘Chronic, relapsing dependence syndrome, reinforced by sensory, behavioural and social conditioning, entrenched by a powerful withdrawal syndrome’. Combined, these factors make it hard for people to give up and they need expert help to succeed.5 

The COVID-19 pandemic

Public Health England (PHE) guidance on COVID-19 advises: if you smoke, you generally have an increased risk of contracting respiratory infections and of developing more severe symptoms once infected. COVID-19 symptoms may, therefore, be more severe if you smoke.6 Smokers are at increased risk of viral and bacterial infections including pneumonia7, risks which can immediately be reduced by quitting. There is also some evidence that current smoking compared with never smoking is associated with greater disease severity in those hospitalised for COVID-19.8  Most smokers report wanting to quit and have tried before. Surveys found that COVID-19 is increasing smokers desire to quit9, although many are finding it difficult to do so.10

Discussing smoking in primary care settings

The best way for people to stop smoking is using a combination of specialist help plus licensed medication, such as short-term and long-term nicotine replacement therapy (NRT), and bupropion or varenicline.10,11

Targeting older smokers in primary care and secondary care would make a big difference because they have a higher risk of becoming ill or dying. In addition, investing time and resources on interventions to assist long-term smokers to quit would benefit their health and reduce costs to the NHS. 

Very Brief Advice

NICE guidance recommends at every opportunity to ask people if they smoke and offer advice on how they can stop, in a way that is sensitive to their preferences and needs.11 Ideally, all smokers would be offered ‘Very Brief Advice’, comprising of the 3As: Ask, Advise and Act. The National Centre for Smoking Cessation and Training (NCSCT) provide online training showing how to apply the 3As in clinical practice.12 After completing a short assessment staff will qualify for a CPD certificate. 

Try starting the conversation with questions such as ‘What have you heard about the risks of smoking and COVID-19?’ ‘What’s getting in your way of stopping?’ or ‘May I explain my concerns?’. Inform smokers of the local support available through the NHS and offer a referral to a stop smoking service. Most services now offer telephone counselling and can post licensed NRT medications out to the patients and in some areas e-cigarette starter packs.

If people are not ready to stop smoking

Help them understand how stopping smoking will reduce their risks of developing smoking-related illnesses or of COVID-19 worsening their current condition and personalise this information. For example, many people with COPD do not understand the immediate advantages of stopping smoking. Ask about the current problems their lung disease is causing, and if they’d like to stop these getting worse? If they are not ready to stop smoking, ask them to consider adopting a harm reduction approach as described in the NICE guideline on smoking: harm reduction.

Harm reduction approaches recommended by NICE13

  • Stopping smoking with the help of at least one licensed nicotine-containing product
  • Cutting down prior to stopping smoking, with or without the help of licensed nicotine-containing products
  • Smoking reduction, with or without the help of licensed nicotine-containing products
  • Temporary abstinence from smoking, with or without the help of licensed nicotine-containing products

Smokers not yet ready to quit could also be signposted to the NHS Smokefree website, a national support platform that provides information on getting support to quit, as well as providing free tools like a Personal Quit Plan, a Smokefree app and support via e-mail or Facebook Messenger.

Support for smokers included in the NHS Long Term Plan14 

The NHS long Term plan states that by 2023/24:

  • All patients admitted to hospital who smoke will be offered NHS-funded tobacco treatment services. Citing the Ottawa Model15, which identifies the smoking status of all admitted patients, offers brief advice, personalised bedside counselling, timely pharmacotherapy and follow up after discharge. 
  • The model will be adapted for expectant mothers, and their partners, with a new smoke-free pregnancy pathway including focused sessions and treatments.
  • A new universal smoking cessation offer will also be available as part of specialist mental health services for long-term users of specialist mental health, and in learning disability services. On the advice of PHE, this will include the option to switch to e-cigarettes while in inpatient settings.

E-cigarette use

E-cigarettes are currently the most popular aid to quitting smoking in England.16 While not completely risk free, switching completely to vaping is significantly less harmful than continuing to smoke. Although these products are not licensed medicines, they are regulated by the Tobacco and Related Products Regulations 2016.11 People who smoke should therefore not be discouraged from switching to e-cigarettes and be advised to only use those and stop using any tobacco.11 The NCSCT recommends that practitioners be open to e-cigarette use among smokers trying to quit, particularly if they have tried other methods of quitting and failed. They have issued guidance for healthcare staff on ways to support people choosing to quit using their own vaping device with or without an NRT product. 17

Summary

During lockdown people have become more aware of their health and there is growing evidence from surveys that people who smoke are more likely to want to quit and stay quit as a result of the COVID-19 pandemic. Quitting confers immediate benefits – for example by lowering blood pressure, reducing respiratory infections and heart disease – which helps ease pressure on the NHS. All smokers need to be supported to take steps to quit or abstain from smoking at this time.

Further information and training
The National Centre for Smoking Cessation and Training (ncsct.co.uk)

Jennifer Percival, independent national stop smoking trainer

This project was initiated and funded by Teva Respiratory. Teva have had no influence over content. Topics and content have been selected and written by independent experts.