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Tobacco dependency expert panel responds

Difficult clinical questions, conversations and responses? The expert panel responds.

Q: My patient smokes cigarettes and has a BMI of 43, they drink 45 units of alcohol a week and their physical activity is limited. What should I do first or is it better to tackle all together?

A: Deal with their presenting issue first. Express concern about weight, alcohol use and smoking: “I am concerned about…and there is something we can do”. Be hopeful and supportive. Deliver VBA for alcohol and smoking and ask the patient what they want to address first – evidence that sequential intervention has better outcomes. This works for most people most of the time.

Q: Won’t people get tired and annoyed of me doing VBA on them?

A: The value of VBA given correctly and with empathy is positive, non-confrontational, engaging and quick. If you understand they have a dependency, you will act with compassion.  People get tired of being told to stop smoking, this is not VBA

In any given year, about 30% of smokers are thinking of making a quit attempt and about half are attempting to cut down. Keep on delivering VBA and you stand a chance of catching a patient who is receptive to your offer of help. Smokers expect to be asked about their smoking by healthcare professionals.

Q: My patients just don’t want to stop, what should I do?

A: In fact most smokers DO want to stop but often feel unable; they know they should stop but don’t know how. This is why VBA is designed to give advice on the best way to quit without telling them to stop. Whenever you encounter a smoker, you should offer them help and hope. Quitting is a process not an event, even a failed quit attempt matters and is a part of the process towards a successful and permanent quit. The motivation to stop smoking can vary even on a daily basis. This is why VBA needs to be repeated as you never know which time you give it will trigger the successful quit.

Q: My patient also smokes marijuana, will VBA work?

A: Your patient’s cannabis use will have to be directly addressed if they decide to quit smoking. Advising the patient that if they smoke cannabis with tobacco this still counts as ‘smoking’ and this continued consumption of tobacco will seriously harm their chances of quitting. Advise to cut out cannabis, at least in the short term, and then you can discuss other methods of using cannabis that do not involve tobacco. The best current evidence for cannabis cessation is with CBT though studies generally are rather limited.

Q: How does VBA differ from motivational interviewing?

A: As its name implies VBA is very brief and does not require any assessment of readiness to quit or exclude those who say they are not ready. Therefore, it includes everyone, every time. Its use will alter the readiness – the motivation – of some and is therefore closer to a universally accessible intervention. Motivational interviewing is a tool that could be used in the follow-up specialist consultation. Motivational interviewing requires more intensive training for effective delivery. Neither VBA or MI should be delivered without training.

Q: Is everyone who smokes dependent on tobacco? What about social smokers?

A: No, but this doesn’t make it safe. Harmful tobacco use is that represented by a shift from 0 to 1 cigarettes The risk of smoking is not linear. Risk of one cigarette per day has been shown to be half that of 20 per day.

Q: I support people to quit and prescribe accordingly but when delivering a COPD update recently was astonished to discover that they have been told that they must not prescribe anything for smoking cessation. I believe this to be the most unethical thing I've heard for some time. If I worked locally I'd ignore it but how do we empower clinicians to challenge diktats such as this in the interests of patient focused care?

A: In England, this situation has arisen as in some areas because the budget for providing smoking cessation products has been diverted to other parts of the healthcare services system. We, as an expert group, believe that behavioural support + pharmacotherapy for smoking cessation is fundamental to helping people to stop. The funding should be provided where treatment is delivered. The medications used for smoking cessation support are available and can be prescribed by GPs as independent prescribers.  Irrespective of local guidance, pharmacotherapy should be prescribed where clinically indicated.

Q: How do we best advise a patient who wishes to buy an electronic cigarette? What pointers should they look for and are they all the same with regards to safety profile? It's all very well saying they need to be 'approved' but how does a patient know what to look for? Is the 'pound shop' ok or a 'vape shop' or the market?

A: As an expert group we are not currently in a position to make any recommendations in this respect. All Vape products in the UK should be registered under the TPD (Tobacco Product Directive); 94% of current commercially available devices are registered. ASH guidance is to seek out a specialist Vape shop and discuss your needs with them. A number of local stop smoking services are also e-cigarette friendly and they will be prepared to discuss these issues with your patient.

Useful resources:

Q: Seeing a patient in the urgent care appointment system in a GP surgery who currently smokes and (1) is attending with a respiratory infection (no respiratory long term condition), (2) a flare up of their respiratory condition or (3) is a smoking parent of child experiencing either 1 or 2.  Do you - in addition to VBA at this moment - routinely recommend as part of their self-management /treatment plan to swap tobacco to NRT or electronic cigarette in order to reduce short term risks/harm?

A: Always start with VBA. If the response to VBA is positive you should seek to engage the patient in a quit attempt. NRT is helpful for managing withdrawal symptoms with a view to quitting. For parents – direct to ROSPA guidance (don’t smoke in the house, use Vape). If a patient is considering using e-cigs, make sure they know all other options available to them and reinforce that the aim should be to quit.

Q: Please can you give us some motivational lines for our patients with COPD who do not want to stop. We often hear the same resistance, for example, 'I've been smoking for too long to stop now' or 'I've tried many times before and I can't do it'.  We are perfectly placed to encourage and support these patients to stop and yet can have very little success so any advice on motivational interviewing to encourage health behaviour change would be great.

A: Start with VBA. When you Advise emphasise that there are quick ways that can help and support rather than reiterating familiar messages on the damage smoking does. Explore the patient’s knowledge and agenda and build your approach on their responses.

Q: The main issue we have with patients, is encouraging those that say to us "What's the point in giving up now? I'm unwell already, so I might as well carry on. It's the only thing I love to do, if I haven't got smoking, I have nothing." "When I try to stop smoking my chest feels worse, I bring up more phlegm and now I'm putting on weight which is making my breathlessness worse." "The only thing that brings my phlegm up, is having a cigarette. It’s better than those exercises you showed me!" How do we encourage these patients to stop?

A: It is always appropriate to be positive about stopping smoking as there is good evidence that individuals who stop smoking will achieve health benefits regardless of their overall health and comorbid conditions. It is likely that some people will notice more phlegm (the body is surprised that there isn’t smoke going in – and is used to producing more phlegm to try to protect itself from the damage – this can take some months to settle).

Latest guidance says e-cigarettes are 95% less harmful than smoking. How best for me as a GP to communicate this to patients? How best can our nurses support patients wanting to quit using e-cigarettes?

There is no combustion (burning) with e-cigarettes and this is the main reason that they are so much less harmful than smoking. Ask your nurses to take the NCSCT e-cigarette course and to read the NCSCT briefing. Your patients can view The Switch suite of films.

Q: Is it worth getting an exhaled carbon monoxide monitor?

A: Yes. It can be a powerful motivational tool. See the Helping Smokers Quit in London advice on exhaled CO.

Q: When and for who should I consider prescribing varenicline?

A: Anyone who wants it and for whom it is not contraindicated. Useful resource: Why and how to prescribe varenicline in hospital