Discussing smoking

COMMUNICATION SKILLS

companion and the mere thought of stopping can cause panic. Many experience a sense of loss in the early stages of stopping that is tantamount to bereavement as they learn to live without their ‘friend’. They are told that they should start to see the cigarette as an enemy that will take years off their life, reduce their quality of life and be a constant drain on their income. • The counsellor should reassure the smoker that withdrawal symptoms will peak in the first week, but largely subside within 3–4 weeks. It is worth discussing withdrawal symptoms in detail (Figure 1). Episodes of craving last for about 6 minutes with a peak at 2–3 minutes, but to smokers who dwell on their need for a cigarette, 6 minutes can feel like 6 hours. It is important to discuss coping strategies for use at times of craving (e.g. a 10-minute task to occupy the mind). • To help motivate the smoker, explain that 120,000 people die of smoking-related diseases each year in the UK. List these diseases, and link them to the habit. However, it is important to explain that it is never too late to stop. Within 48 hours of stopping smoking, no carbon monoxide or nicotine remains in the body, regardless of how long or how many cigarettes the patient has smoked. The risks of heart attack and stroke also start to decrease within 48 hours, and the risk of lung cancer declines steadily over the years after stopping. Further deterioration of bronchitis and emphysema slows to the normal age-related rate. • The composition of cigarettes should be explained. Smokers are often shocked to learn that each cigarette contains 4000 chemicals, 60 of which are carcinogenic. At this point, it is appropriate to list the cancers caused by smoking, and to explain that nicotine and carbon monoxide cause arterial narrowing and reduce oxygen delivery, leading to heart disease, strokes and peripheral vascular disease. Mention that nicotine also increases blood pressure and heart rate. Smokers use cigarettes to manage stress, pain, anger and frustration, to regulate mood and to manage weight. From the patient’s smoking history, it is helpful to establish the relative extents to which nicotine dependency and psychological dependency contribute to his or her habit. Ask about: • the age at which the person started smoking • the number of cigarettes smoked each day • how soon the person smokes after waking • any other smokers in the home • previous attempts at stopping – aids used, withdrawal symptoms, success, reasons for failure • motivation for stopping (e.g. health, finance, family). With this information, the counsellor is better equipped to increase the smoker’s confidence about stopping and to decide which type of aid is most appropriate. Smokers may decide to stop suddenly or gradually, using willpower alone or with nicotine replacement therapy or bupropion. In all cases, they should be asked to set a date for stopping. They may have tried to stop smoking and failed in the past, but this does not mean they will not succeed on this new attempt.

Discussing smoking Sonja Edwards Ian A Campbell

Smoking cessation is not easy, and smokers who manage to stop usually make more than one attempt before they succeed. In the one-to-one programme used in the authors’ unit, success is defined as verified abstinence at 1, 3, 6, and 12 months and claimed abstinence between appointments from 3 months onwards. Success depends on motivation, planning and support. There is little or no hope of persuading a smoker to stop if he or she does not want to do so. To help motivate smokers, the counsellor must determine their smoking profile and explain the risks of smoking and the benefits of quitting. The counsellor must also ascertain whether smokers are ready to stop and, if they are, help them to decide whether this will be immediately or in the near future. Advice and support are particularly necessary in the first few weeks after stopping.

Initial session During the first session in the cessation programme, the counsellor should explain that most ex-smokers believed that they would succeed at the first attempt, but most needed a few attempts. The smoker should be left with no doubt that nicotine is a powerful drug with a range of mental and psychological effects, including: • reduced anxiety • improved memory • feelings of alert relaxation • enhanced pleasure • enhanced attention. Understanding the effects of nicotine should make it easier to stop, and booklets can be provided describing the risks of smoking and the benefits of stopping. • The smoker should be told that the thought of stopping can be worse than doing so, and the counsellor should try to alleviate his or her fear. To many smokers, the cigarette is a friend or

Sonja Edwards is Smoking Cessation Counsellor at Llandough Hospital, Cardiff, UK. She qualified from the Central School of Counselling Therapy, London. Ian A Campbell MBBS BSc FRCP MD is Consultant Chest Physician at Llandough Hospital, Cardiff, UK. He qualified from St George’s Hospital, London, and has worked in London, Oxford, Edinburgh, Plymouth and Bristol. His research interests include smoking cessation, mycobacterial disease, pulmonary venous thromboembolism and osteoporosis in asthma.

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Hints for stopping smoking Stopping smoking requires hard work, effort, concentration and knowledge about the addiction. The role of the counsellor is to keep the smoker focused, motivated and supported, and to help plan for success. 55

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COMMUNICATION SKILLS

Coping with withdrawal symptoms Symptons

Usual duration

Hints

• Dizziness

1–2 days

It will pass

• Tiredness

Varies

Relax

• Coughing

< 7 days

Take more exercise and sleep

• Tightness in chest

< 7 days

It will pass

• Trouble sleeping

< 7 days

Do not drink caffeine in the evening

• Constipation

3–4 weeks

Drink lots of water, eat high-fibre foods

• Hunger

Several weeks

Eat low-calorie snacks

• Irritability

Several weeks

Be prepared, and prepare family

• Loss of concentration

Several weeks

Be prepared

• Craving for cigarettes

Strong for the first

Do something else

2 weeks, then intermittent 1

Defences and rewards It can be helpful for the smoker to collect old cigarette ends in a jar of water and display this in a prominent place for at least 3 months after stopping. This acts as aversion therapy, and can be incorporated into the ‘10-minute task’ routine. If craving occurs, looking at the jar and, if necessary, taking the lid off and smelling its contents should be a sufficient defence. The cigarette is no longer a friend – it is an enemy. Next to the butt-end jar, the patient is advised to keep another jar in which he or she places the money that would have been spent on cigarettes. Suggest that the money is banked regularly, to use for a holiday, a treat or some other pleasure. This is the patient’s reward for stopping smoking.

ing. Provide a leaflet on sensible eating and monitor the person’s weight during the programme. Advise snacking on fruit and vegetables between meals and encourage more exercise, if possible. It can be helpful to drink more water and use sugar-free chewing

Follow-up programme First month Weekly sessions

Daily diary Smokers should be advised to keep a diary from the stop date, with the benefits of stopping smoking listed at the front. On completing his or her first day without cigarettes, the smoker should write the word ‘success’ at the bottom of the page and make a note of how much money is saved in the jar. Health gains such as improved taste or smell and reduced breathlessness should also be listed as they occur. The diary can also help in dealing with relapses. Relapses are not unexpected because nicotine is habit-forming and addictive, but the smoking of one cigarette is not a licence to smoke more – the patient should make an effort to get to the end of the day without another. Relapses should be viewed as learning experiences, not failures; the smoker has learned more about his or her addiction and is therefore stronger. Any such learning experience is recorded in the diary, including the date, the time, and what triggered use of the cigarette (e.g. habit, boredom, an argument); future problems can be anticipated by thinking ahead one day at a time. The diary should be brought to follow-up appointments and discussed with the counsellor, noting the reasons for relapses and what coping strategies could have been used.

2 months Telephone call or letter from counsellor to encourage/support 3 months Cessation validated by measurement of expired air carbon monoxide 5 months Telephone call or letter from counsellor to encourage/support 6 months Cessation validated by measurement of expired air carbon monoxide 9 months Telephone call or letter from counsellor to encourage/support 12 months Cessation validated by measurement of expired air carbon monoxide Patients are encouraged to contact counsellor for support/advice between appointments

Weight gain Many smokers, particularly women, ask about weight gain. Eating a sensible diet is preferable to strict diets when trying to stop smok-

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2

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EVIDENCE, AUDIT, GUIDELINES

NICE and its schizophrenia guidelines

gum. It should be emphasized that smoking-related diseases are more dangerous than gaining a few extra pounds in weight. The first priority is to stop smoking. Support at home The smoker is asked to identify a friend or relative who can be a steady source of support to act as his or her ‘minder’. Children or grandchildren are often the best minders, because a promise to a child is harder to break. Older children can make a chart to plot success and ‘learning cigarettes’ with the smoker. It is advisable to remove cigarettes, ashtrays and lighters from the home, but many smokers fear that if an emergency were to occur, they would crave a cigarette more or, possibly, panic. Smokers who are upset at the thought of having no cigarettes in the home are advised to seal a packet thoroughly with large amounts of adhesive tape and keep this for emergencies only. By the time they have broken into the packet, the 6 minutes of craving may have passed.

Richard Gray

‘Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care’ was published by the National Institute for Health and Clinical Excellence (NICE) in December 2002.1 The schizophrenia guideline was the first to be published by NICE and took almost two years to develop. The guideline has been widely disseminated to a variety of stakeholder groups and can be downloaded from the NICE website (www.nice.org.uk). The development group responsible for the guideline included professionals from a variety of disciplines, service users and carers. The guideline addresses the major treatments and services for people with schizophrenia, is evidence based, and each recommendation is graded according to the level of evidence. Health professionals are expected to take the guideline into account when exercising their clinical judgement. In practice, where clinicians and users choose to deviate from guideline recommendations they should document their reasons for this.

Follow-up In follow-up sessions (Figure 2), it is important to find positive gains, particularly when the smoker is not doing well. The counsellor should ensure that the smoker never feels a failure at the end of a session. Reinforcement of lessons learned about the addictive nature of smoking should motivate the patient to try again. The attitude of smoking-cessation counsellors (or any health professional advising smokers) should be one of warmth, understanding, acceptance and respect. Smokers must feel that they are not ‘lepers’ and that the counsellor genuinely understands and wishes to help them stop smoking. Smokers who feel that they are being lectured or pressurized are unlikely to be helped by the counsellor. 

What are clinical guidelines? It is impossible for clinicians to assimilate, evaluate and implement the ever-increasing amount of evidence and opinion about current best practice. Clinical guidelines are systematically developed statements to assist health workers and service users make decisions about appropriate healthcare for specific clinical conditions based on the best available evidence. They are a way of bridging the gap between academic research and everyday practice. Guidelines are also important and useful to health service managers and commissioners to inform service planning and development. Guidelines are meant to assist clinical practice but do not replace good clinical knowledge and skills. One of the major problems with clinical guidelines is that they are necessarily general and there are many instances when they will not be appropriate for an individual user. Over recent years there has been an increase in the number of clinical guidelines published in different countries and this has stimulated much debate on their value. Concern has been expressed about: • their quality • whether they are based on the best scientific evidence • how effective they are in real clinical practice.2

FURTHER READING Campbell I A. Smoking cessation. Thorax 2000; 55: (Suppl. 1): S28–31. Prathiba B V, Tjeder S, Phillips C et al. A smoking cessation counsellor: should every hospital have one? J Roy Soc Health 1998; 118: 356–9. Campbell I A. Smoking. In: Seaton A D, Haslett C, Leitch A G et al., eds. Crofton and Douglas’s respiratory diseases. 5th ed. Oxford: Blackwell Scientific, 2000: 311–23.

Practice points • Motivation is essential for successfully stopping smoking • Describe possible withdrawal symptoms and how to cope with them; alleviate the fear of stopping • Advice and support are vital, and should include hints on maximizing the likelihood of success and pharmacological aids • Convey warmth, understanding, acceptance and respect; never lecture or pressurize smokers, and do not make them feel a failure

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Richard Gray RN PhD is Senior Lecturer at the Institute of Psychiatry, King’s College London, UK. He trained at King’s College, London as a Mental Health Nurse. His research experience includes observational and analytical work in treatment adherence, sexual health, physical health, the management of violence and non-medical prescribing.

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