Clearing the Smoke: A Guide to Preventing and Treating Tobacco Dependence

Smoking remains one of the leading causes of preventable death. NICE has today produced an updated Guideline, [NG209], on providing support to stop smoking for everyone aged 12 and over. It promotes quitting and supports those trying to break free from nicotine dependence. It also aims to reduce people’s harm from smoking if they are not ready to stop in one go. Furthermore, it outlines strategies to prevent children and young people from taking up smoking. In this quick post we look at the broad themes covered in the guideline. In future posts we will spend more time on the specific interventions discussed in it.

Preventing the Uptake of Smoking

Prevention is the first line of defense against smoking-related harm. Several approaches can help reduce tobacco uptake, particularly among young people:

• Public Awareness Campaigns: Well-designed, long-term mass-media campaigns target individuals under 18. They can help denormalize smoking. Such campaigns highlight the dangers of tobacco use. They should integrate digital, print, and televised media to reach diverse audiences effectively.
• School-Based Interventions: Schools play a vital role in prevention. They implement adult-led and peer-led programs. These programs teach students about self-esteem. They also cover resisting peer pressure and the risks of smoking. These programs should be evidence-based and adapted to different age groups.
• Retail Regulation: Stronger enforcement of age restrictions, test purchasing programs, and retailer awareness campaigns can help prevent underage tobacco sales. Providing retailer training on compliance can further reduce illegal sales.
• Community Policies: Creating smoke-free zones in schools, workplaces, and public spaces sends a clear message. It reinforces the idea that smoking is not a social norm. Policies should be backed by community engagement initiatives to promote widespread support.

Identifying and Quantifying Smoking Behavior

Routine identification of smokers is essential for effective intervention. Key strategies include:

• Screening at Every Healthcare Interaction: Simple questions about smoking history and habits help healthcare providers offer targeted support. This includes identifying occasional smokers and those exposed to secondhand smoke.
• Assessing Nicotine Dependence: Evaluating cigarette consumption, withdrawal symptoms, and time to first cigarette provides insight into addiction severity. Carbon monoxide testing can offer additional objective data.
• Data Recording and Follow-Up: Maintaining accurate patient records ensures continuity of care and enhances future interventions. Healthcare providers should schedule follow-ups to assess progress and adjust treatment plans.

Effective Stop-Smoking Interventions

Helping people quit requires a combination of behavioral and pharmacological approaches:

• Behavioral Support: One-on-one counseling, group therapy, and cognitive behavioral therapy (CBT) can improve quit rates. Digital health interventions, such as mobile apps and text message reminders, can also be beneficial.
• Pharmacotherapy: Medications like nicotine replacement therapy (NRT), varenicline, and bupropion are proven to aid smoking cessation. The guideline also looks at cytisinicline (sometimes referred to as cytisine). Healthcare providers should educate patients on their proper use to maximize effectiveness.
• E-Cigarettes as a Harm Reduction Tool: Although not medicinally licensed, e-cigarettes may help individuals transition away from tobacco use. Patients should be guided on choosing appropriate products and monitored for potential side effects.
• Quitline Support: Telephone-based quit services offer convenient, evidence-based guidance for those seeking to stop smoking. These services should be promoted through primary care and pharmacy settings.

Supporting Smoking Cessation in Primary and Secondary Care

Both primary and secondary care settings play a critical role in smoking cessation:

• Primary Care Strategies: Very Brief Advice (VBA) should be a routine practice in GP clinics and pharmacies. Referrals to stop-smoking services should also be routine in these settings. Providing easy access to self-help materials and digital resources can further support patients.
• Secondary Care Interventions: Providing pre-admission education, bedside support during hospital stays, and post-discharge follow-up can enhance quit success rates. Hospital settings should also ensure access to NRT and other pharmacotherapies.
• Integration Across Services: Ensuring continuity of care between hospital services, primary care providers, and community-based support networks helps prevent relapse. This integration reinforces quit attempts.

Helping Those Not Ready to Quit

Not all smokers are ready to quit immediately, but harm reduction strategies can still benefit them:

• Encouraging Reduction Before Quitting: Gradual reduction of smoking, supported by NRT, can help ease dependence. Patients should be encouraged to set reduction goals and track their progress.
• Temporary Abstinence Support: Using nicotine alternatives in smokefree environments can be encouraged. These environments include workplaces or hospitals. This approach can contribute to longer-term reductions. Patients should also be educated on managing cravings in restricted areas.
• Ongoing Motivational Support: Engaging in open, judgment-free conversations encourages future quit attempts. Motivational interviewing techniques can be effective in guiding individuals toward readiness for change.

Addressing Smokeless Tobacco Use

Smokeless tobacco products pose unique health risks, requiring targeted interventions:

• Educating Users About Risks: Increased awareness of the dangers, including oral cancers and heart disease, can encourage cessation. This is particularly important in communities where smokeless tobacco use is more prevalent.
• Culturally Sensitive Counseling: Tailored interventions can support communities where smokeless tobacco use is more prevalent. Healthcare providers should receive training on cultural considerations and language barriers.
• Pharmacotherapy for Smokeless Tobacco Users: NRT and other medical aids may assist in breaking dependence. These should be combined with behavioral support to improve outcomes.

Preventing Relapse and Ensuring Long-Term Success

• Continued Support and Follow-Ups: Regular check-ins with patients can reinforce progress and address challenges. Patients should be encouraged to discuss their triggers and coping strategies.
• Combination Therapy: A mix of behavioral counseling and pharmacotherapy increases the likelihood of long-term success. Patients should be informed about the benefits of using multiple quit methods simultaneously.
• Community Engagement: Peer support groups and workplace cessation initiatives create additional layers of encouragement. Employers can play a role by offering cessation programs and incentives for quitting.
• Monitoring Medication Interactions: Some prescription medications may require dose adjustments when a patient quits smoking. This is because smoking can affect drug metabolism. Healthcare providers should monitor and adjust prescriptions as needed.

Special Considerations: Smoking Cessation During Pregnancy

Pregnant smokers require tailored interventions to protect both maternal and fetal health:

• Routine Screening: Identifying smoking status early in pregnancy allows for timely intervention. Partners of pregnant smokers should also be encouraged to quit.
• Behavioral Counseling: Providing specialized support for pregnant smokers and their partners increases quit rates. Sessions should address stress management and barriers to quitting.
• Safe Pharmacotherapy Options: NRT can be prescribed as a safer alternative to smoking, ensuring careful monitoring and dosage adjustments. Pregnant individuals should be informed about the risks and benefits of pharmacotherapy.
• Postpartum Support: Preventing relapse after childbirth helps maintain a smokefree home environment for infants. Breastfeeding mothers should be given guidance on NRT use and secondhand smoke exposure.

Final Thoughts

By implementing these comprehensive strategies, we can reduce smoking initiation, support those trying to quit, and ensure long-term cessation success. Collaboration between healthcare providers, policymakers, and communities is essential to creating a smokefree future.

We invite you to also subscribe to our Podcast, The GP Pharmacy Club Pod. In this week’s episode, Adam and Amanda discuss this updated guideline. Search for “The GP Pharmacy Club Pod,” on Apple Podcasts, Amazon Music and Spotify. You make also find the episodes on our website, here.