You’re Not Alone
Evidence shows that two-thirds of smokers say they want to quit, however most try to do so unaided, which is the least effective method. Smokers who get the right support are 3 times as likely to quit successfully. There are a range of “quit smoking” routes that are available and evidence for their effectiveness.
Smoking is the leading cause of preventable illness and premature death in America, with about half of all life-long smokers dying prematurely, losing on average around 10 years of life. In 2016 alone, there were around 480,000 deaths attributable to smoking.
The Evidence On Nicotine
Perhaps the greatest obstacle we face is the widespread misconception amongst smokers and health professionals that most of the harm of smoking comes from the nicotine.
While nicotine is the addictive substance in cigarettes, it is relatively harmless. In fact, almost all of the harm from smoking comes from the thousands of other chemicals in tobacco smoke, many of which are toxic.
Nicotine replacement therapy is a safe form of treatment and licensed for use even in pregnancy and for people with cardiovascular disease. Nicotine increases heart rate and blood pressure, and has a range of local irritant effects, but is not a carcinogen. It is the tar and carbon monoxide in cigarette smoke, along with over 400 other toxins, that causes almost all of the harm of smoking.
Smoking And Health Inequalities
As smoking prevalence has declined, it has become increasingly concentrated among more disadvantaged communities and groups:
- Around 1 in 4 people in routine and manual occupations smoked, compared with 1 in 10 people in managerial and professional occupations.
- People who are unemployed are almost twice as likely to smoke as those in work.
- Smoking prevalence among adults with a serious mental illness is over two and a half times the national average.
Smoking during pregnancy is also a major health inequality, with prevalence varying significantly across communities and social groups:
- Smoking prevalence among pregnant women in more disadvantaged groups and those aged under 20 remains considerably higher than in older and more affluent groups.
- Mothers in routine and manual occupations are 5 times more likely to have smoked throughout pregnancy compared to women in managerial and professional occupations.
- The decline in the prevalence of smoking during pregnancy has stalled in recent years, with over 1 in 10 babies in England born to a mother who smoked throughout her pregnancy.
- Latest figures from NHS Digital found that 10.4% of pregnant women were known to be smokers at the time of delivery.
In some areas, this is as high as 1 in 4. Reducing smoking during pregnancy is one of the three national ambitions in the Tobacco Control Plan: “reducing smoking amongst pregnant women (measured at the time of giving birth) to 6% by the end of 2022”.Just 33 out of 195 Clinical Commissioning Groups (CCGs) in England met the national ambition of 6% or less.
Creating A Smokefree Society: The Role Of The NHS
Although there are now 1 million fewer smokers than in 2014, 6.1 million adults in England are still subject to the devastating harm tobacco causes. Therefore, reducing smoking remains one of PHE’s key priorities.
PHE is calling for the NHS long-term plan to commit to achieving a smokefree society by 2030 with an adult prevalence of 5% or less.
Smoking is not a lifestyle choice but a long-term relapsing condition. Every patient or staff member who smokes must be offered the support they need to quit and PHE wants to see NHS trusts stepping up their efforts in establishing a smokefree NHS by 2020.
Reducing smoking rates is the single biggest thing we can do to improve the nation’s health. It will reduce cardiovascular disease, respiratory conditions, and cancer, meaning people can live longer in better health, and according to the Royal College of Physicians (RCGP) it will save the NHS up to £890 million a year.
Stop smoking support options and their effectiveness
In England, around 60% of smokers want to quit, 10% of whom intend to do so within 3 months.
Currently, around half of all smokers in England try to quit unaided using willpower alone, despite this being the least effective method. Getting support can greatly increase a person’s chances of quitting successfully:
- Using nicotine replacement therapies (NRT) or e-cigarettes makes it one and a half times as likely a person will succeed.
- A person’s chances of quitting are doubled if using a stop smoking medicine prescribed by a GP, pharmacist or other health professionals.
- Combining stop smoking aids with expert support from local stop smoking services makes someone 3 times as likely to stop smoking successfully.
- The following section details the range of quitting methods and their effectiveness.
Expert face-to-face support
There is clear evidence that the most effective way to quit smoking is with expert behavioural support from local stop smoking services combined with stop smoking aids. These include the prescription tablets Varenicline and Bupropion, nicotine replacement therapies and e-cigarettes. Smokers who get this package of support are 3 times as likely to quit successfully as those who try to quit unaided or with over the counter nicotine replacement therapy.
Prompts by healthcare professionals are the second most common reason for someone to make a quit attempt. Effective referral routes from both primary and secondary healthcare are important to ensure that all smokers who need it get this specialist support. GPs are normally the first point of contact for patients.
As a matter of routine, they should make every contact count and identify smokers and offer smoking cessation interventions. It is, therefore concerning that the number of smokers receiving an offer of support from in primary care has been falling steadily for a number of years.
Nicotine Replacement Therapy (NRT)
NRT is a medicine that provides users with nicotine without the tar, carbon monoxide and other poisonous chemicals present in tobacco smoke. It can help to reduce tobacco withdrawal symptoms such as irritability and cravings.
NRT is available over the counter as well as on prescription. It is available as:
- Skin patches
- Chewing gum
- Oral strips
- Nasal and mouth sprays
NRT is an effective stop smoking method, increasing chances of stopping smoking for 6 months or more by more than half. There is also good evidence to show that combination NRT is more effective than single product use.
A nicotine patch releases nicotine slowly into the body’s system to help keep it on a constant level, while a fast-acting product such as an inhaler, lozenge or gum helps with immediate cravings. NICE recommends that combination NRT should be considered as a viable option for all smokers wanting to quit. For further information, see the NCSCT briefing ‘Combination nicotine replacement therapy’.
Nicotine is addictive but the level of addictiveness depends on the delivery system. The addictiveness of tobacco cigarettes is enhanced by compounds in the smoke other than nicotine. NRT products are available in different strengths so that nicotine intake can be gradually reduced when the person feels ready. Premature cessation of NRT is associated with relapse to smoking.
An e-cigarette allows the user to inhale nicotine through a vapor rather than smoke. E-cigarettes come in a variety of models and work by heating solution (e-liquid) that typically contains nicotine, propylene glycol and or vegetable glycerin and flavorings.
At present, there is no medicinally licensed e-cigarette product available on the UK market. However, the UK has some of the strictest regulation for e-cigarettes in the world. Under the Tobacco and Related Products Regulations 2016, e-cigarette products are subject to minimum standards of quality and safety, as well as packaging and labelling requirements to provide consumers with the information they need to make informed choices. All e-cigarette products must be notified by manufacturers to the UK Medicines and Healthcare products Regulatory Agency (MHRA), with detailed information including the listing of all ingredients.
Leading UK health and public health organisations including the RCGP, BMA and Cancer Research UK now agree that although not risk-free, e-cigarettes are far less harmful than smoking. Based on an assessment of the available international peer-reviewed evidence, PHE and the RCGP estimate the risk reduction to be at least 95%. In 2018 so far, 3 major US reports (National Academies of Sciences, Engineering and Medicine, American Cancer Society and the US Annual Review of Public Health) have found that e-cigarettes are substantially less harmful than smoking.
E-cigarettes are currently the most popular stop smoking aid in England, with an estimated 2.5 million users. Over half (51%) have stopped smoking completely and of the 45% who still smoke, half say that they are vaping in order to stop smoking. The number who have quit both smoking and quit vaping has reached 770,000.
There is growing evidence that e-cigarettes are helping many thousands of smokers in England to quit. The available evidence from research trials suggests that their effectiveness is broadly similar to prescribed stop smoking medicines and better than NRT products if these are used without any professional support. E-cigarettes are particularly effective when combined with expert help from a local stop smoking service. In 2017 to 2018, around two-thirds of smokers who got this support stopped smoking successfully.
Local stop smoking services have an important role to play in supporting smokers who want to use an e-cigarette in their quit attempt. Yet currently, only around 4% of those using stop smoking services are using an e-cigarette in their quit attempt. Clearly, more can be done to combine the popular quitting method with the most effective quitting aid, to maximise the number of smokers quitting successfully.
NICE guidance NG92 recommends that health and social care professionals provide the following advice to smokers who are using, or interested in using, an e-cigarette for quitting:
- Although these products are not licensed medicines, they are regulated by the Tobacco and Related Products Regulations 2016.
- Many people have found them helpful to quit smoking cigarettes.
- People using e-cigarettes should stop smoking tobacco completely because any smoking is harmful.
- The evidence suggests that e-cigarettes are substantially less harmful to health than smoking but are not risk-free.
- The evidence in this area is still developing, including evidence on the long-term health impact.
The RCGP’s recommendations for primary care clinicians together with a video podcast setting out the evidence to help inform conversations with patients about e-cigarettes, can be found here.