RESPIRATORY CARE
Smoking and respiratory disease: the role of the community nurse Camilla Peterken
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The relationship between smoking and respiratory disease has long been established and smoking is recognised as a risk factor for chronic obstructive pulmonary disease (COPD) (Fletcher and Peto, 1977), lung cancer (Doll et al, 2004) and interstitial lung diseases (Bradley et al, 2008), as well as contributing to the symptoms of asthma (Siroux et al, 2000). However, when working with patients who have lived with their disease for some time, or who may feel it is too late to benefit from change, it is important to do more than simply reiterate the risks. The link between continued smoking, progression of respiratory disease, exacerbation of the condition and the detrimental effects of continued smoking on the efficacy of some treatments should also be communicated. This article looks at the risks of smoking, as well as providing guidance for community nurses on how to bring up the topic with their patients in a non-confrontational manner.
that are narrowed and hardened by the interaction of toxins with cholesterol and which leads to a build-up of fatty deposits on the artery walls. However, carbon monoxide is removed from the lungs in just 24 hours and the positive benefits to breathing and circulation can be seen within months (US Department of Health and Human Services, 1990).
KEYWORDS:
EFFECTS OF SMOKING
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Nicotine itself is not the primary cause of harm from smoking, but it is a known stimulant and highly addictive. The main reason that people continue to smoke is that they are addicted to nicotine and the unpleasant withdrawal symptoms prevent them from sustaining cessation.
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he growth of an ageing population in the UK means that patients with chronic and multiple disease are more common (Department of Health [DH], 2013). One of the most important challenges for the future of health care is how to improve quality of life for people living at home with long-term disease for ever-longer periods of time. Community nurses working to avoid hospital admission for their patients will be only too aware of the cycle of chronic disease management, exacerbation, hospital admission, discharge and yet further exacerbation.
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COPD Smoking Respiratory disease Screening
It is by interrupting this cycle that community nurses can make the most valuable contribution to people who smoke — namely, to enable them to improve their quality of life and avoid admission by stopping smoking. After all, if nurses are not letting patients know what they can do to help themselves make a difference, they are missing out an essential element of primary care. Camilla Peterken, smoking cessation specialist,service development, training and change management specialist, the Nyvej Partnership
72 JCN 2014, Vol 28, No 4
Tobacco smoke contains more than 4,000 chemicals, many of which are known irritants (Richter et al, 2008). Nicotine is addictive and keeps people smoking, but it is the combination of tars, carcinogens, metals and free radicals that are toxic and cause greatest harm. Smoking also causes carbon monoxide to attach itself to haemoglobin to form carboxyhaemagloblin, which reduces the oxygen-carrying capacity of the blood and its subsequent supply to the tissues (Morgado et al, 1994). This affects both cardiac and respiratory function — the heart has to work harder to pump less oxygenated blood through arteries
The tar present in cigarettes contains carcinogens that are readily transferred from the lungs to the bloodstream, causing cancers in many different sites of the body (Dresler, 2003). Seventy percent of inhaled tar stays within the lungs and directly affects lung function. Tar also induces specific liver enzymes, which increase the metabolism of some drugs, reducing their efficacy (Zevin and Benowitz, 1999).
THE SCIENCE — WHY IS NICOTINE SO ADDICTIVE? One of the effects of nicotine is to increase the release of dopamine — a neurotransmitter in the brain responsible for feelings of wellbeing. When nicotine is inhaled, it is transported through the bloodstream to the brain where it produces sensations of pleasure and relaxation, eventually causing dependency. Also, the more nicotine is consumed, the more the brain becomes used to it, meaning more consumption is needed to deliver the same effect. When people stop smoking, the amount of nicotine in the body drops, causing a reduction in the levels of dopamine — this, in turn, can result in feelings of anxiety and irritability.
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NICORETTE® Invisi Patch Prescribing Information: Presentation: Transdermal delivery system available in 3 sizes (22.5, 13.5 and 9cm2) releasing 25mg, 15mg and 10mg of nicotine respectively over 16 hours. Uses: NICORETTE® Invisi Patch relieves and/or prevents craving and nicotine withdrawal symptoms associated with tobacco dependence. It is indicated to aid smokers wishing to quit or reduce prior to quitting, to assist smokers who are unwilling or unable to smoke, and as a safer alternative to smoking for smokers and those around them. NICORETTE® Invisi Patch is indicated in pregnant and lactating women making a quit attempt. If possible, NICORETTE® Invisi Patch should be used in conjunction with a behavioural support programme. Dosage: It is intended that the patch is worn through the waking hours (approximately 16 hours) being applied on waking and removed at bedtime. Smoking Cessation: Adults (over 18 years of age): For best results, most smokers are recommended to start on 25mg/16 hours patch (Step 1) and use one patch daily for 8 weeks. Gradual weaning from the patch should then be initiated. One 15mg/16 hours patch (Step 2) should be used daily for 2 weeks followed by one 10mg/16 hours patch (Step 3) daily for 2 weeks. Lighter smokers (i.e. those who smoke less than 10 cigarettes per day) are recommended to start at Step 2 (15mg) for 8 weeks and decrease the dose to 10mg for the final 4 weeks. Those who experience excessive side effects with the 25mg patch (Step 1), which do not resolve within a few days, should change to a 15mg patch (Step 2). This should be continued for the remainder of the 8 week course, before stepping down to the 10mg patch (Step 3) for 4 weeks. If symptoms persist the advice of a healthcare professional should be sought. Adolescents (12 to 18 years): Dose and method of use are as for adults however, recommended treatment duration is 12 weeks. If longer treatment is required, advice from a healthcare professional should be sought. Smoking Reduction/Pre-Quit: Smokers are recommended to use the patch to prolong smoke-free intervals and with the intention to reduce smoking as much as possible. Starting dose should follow the smoking cessation instructions above i.e. 25mg (Step 1) is suitable for those who smoke 10 or more cigarettes per day and for lighter smokers are recommended to start at Step 2 (15mg). Smokers starting on 25mg patch should transfer to 15mg patch as soon as cigarette consumption reduces to less than 10 cigarettes per day. A quit attempt should be made as soon as the smoker feels ready. When making a quit attempt smokers who have reduced to less than 10 cigarettes per day are
recommended to continue at Step 2 (15mg) for 8 weeks and decrease the dose to 10mg (Step 3) for the final 4 weeks. Temporary Abstinence: Use a NICORETTE® Invisi Patch in those situations when you can’t or do not want to smoke for prolonged periods (greater than 16 hours). For shorter periods then an alternative intermittent dose form would be more suitable (e.g. NICORETTE® inhalator or gum). Smokers of 10 or more cigarettes per day are recommended to use 25mg patch and lighter smokers are recommended to use 15mg patch. Contraindications: Hypersensitivity. Precautions: Unstable cardiovascular disease, diabetes mellitus, renal or hepatic impairment, phaeochromocytoma or uncontrolled hyperthyroidism, generalised dermatological disorders. Angioedema and urticaria have been reported. Erythema may occur. If severe or persistent, discontinue treatment. Stopping smoking may alter the metabolism of certain drugs. Transferred dependence is rare and less harmful and easier to break than smoking dependence. May enhance the haemodynamic effects of, and pain response, to adenosine. Keep out of reach and sight of children and dispose of with care. Pregnancy and lactation: Only after consulting a healthcare professional. Side effects: Very common: itching. Common: headache, dizziness, nausea, vomiting, GI discomfort; Erythema. Uncommon: palpitations, urticaria. Very rare: reversible atrial fibrillation. See SPC for further details. NHS Cost: 25mg packs of 7: (£9.97); 25mg packs of 14: (£16.35); 15mg packs of 7: (£9.97); 10mg packs of 7: (£9.97). Legal category: GSL. PL holder: McNeil Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG. PL numbers: 15513/0161; 15513/0160; 15513/0159. Date of preparation: Feb 2012 Nicorette QuickMist Prescribing Information: Presentation: oromucosal spray containing 13.2 ml solution. Each 0.07 ml contains 1 mg nicotine, corresponding to 1 mg nicotine/spray dose. Uses: Relieves and/or prevents craving and nicotine withdrawal symptoms associated with tobacco dependence. It is indicated to aid smokers wishing to quit or reduce prior to quitting, to assist smokers who are unwilling or unable to smoke, and as a safer alternative to smoking for smokers and those around them. It is indicated in pregnant and lactating women making a quit attempt. Dosage: Adults and Children over 12 years of age: The patient should make every effort to stop smoking completely during treatment with Nicorette QuickMist. One or two sprays to be used when cigarettes normally would have been smoked or if cravings emerge. If after the first spray cravings are not controlled within a few
minutes, a second spray should be used. If 2 sprays are required, future doses may be delivered as 2 consecutive sprays. Most smokers will require 1–2 sprays every 30 minutes to 1 hour. Up to 4 sprays per hour may be used; not exceeding 2 sprays per dosing episode and 64 sprays in any 24-hour period. Nicorette QuickMist should be used whenever the urge to smoke is felt or to prevent cravings in situations where these are likely to occur. Smokers willing or able to stop smoking immediately should initially replace all their cigarettes with the Nicorette QuickMist and as soon as they are able, reduce the number of sprays used until they have stopped completely. When making a quit attempt behavioural therapy, advice and support will normally improve the success rate. Smokers aiming to reduce cigarettes should use the Mouthspray, as needed, between smoking episodes to prolong smoke-free intervals and with the intention to reduce smoking as much as possible. Contraindications: Children under 12 years and Hypersensitivity. Precautions: Unstable cardiovascular disease, diabetes mellitus, G.I disease, uncontrolled hyperthyroidism, phaeochromocytoma, hepatic or renal impairment. Stopping smoking may alter the metabolism of certain drugs. Transferred dependence is rare and both less harmful and easier to break than smoking dependence. May enhance the haemodynamic effects of, and pain response to, adenosine. Keep out of reach and sight of children and dispose of with care. Pregnancy & lactation: Only after consulting a healthcare professional. Side effects: Very common: dysgeusia, headache, hiccups, nausea and vomiting symptoms, dyspepsia, oral soft tissue pain and paraesthesia, stomatitis, salivary hypersecretion, burning lips, dry mouth and/ or throat. Common: dizziness, vomiting, flatulence, abdominal pain, diarrhoea, throat tightness, fatigue, chest pain and discomfort, toothache. Other: palpitations, atrial fibrillation, dyspnoea, bronchospasm. See SPC for further details. NHS Cost: 1 dispenser pack £12.12, 2 dispenser pack £19.14. Legal category: GSL. PL holder: McNeil Products Ltd, Roxborough Way, Maidenhead, Berkshire, SL6 3UG. PL number: 15513/0357. Date of preparation: October 2013
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to McNeil Products Limited on 01344 864 042. Date of preparation: April 2014
UK/NI/14-2910
RESPIRATORY CARE
Deaths from smoking
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Nearly 20 years later, smoking still has a significant impact on the population, notably the increasing number of patients living with chronic diseases caused by smoking and the decreasing quality of life caused by continued smoking. This is where the community nurse can play a significant role.
ASTHMA For every 1% increase in smoking prevalence in the asthma population, there is a 1% increase in asthmarelated admissions to hospital (Purdy et al, 2011). Active smokers will experience more severe asthma 74 JCN 2014, Vol 28, No 4
Persistent cough
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A chronic or persistent cough lasting for more than eight weeks is common in the community and can be a sign of various conditions including asthma and COPD, and, less commonly, lung cancer, as well as a reaction to some procedures such as nasal drips. However, in the case of malignancy, there will also be accompanying signs such as haemoptysis (coughing-up of blood), weight loss, chest pain, and a positive smoking history. It is always important to investigate the reasons for a persistent cough (it may simply be a response to a work-based irritant for instance), and refer on if necessary.
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COPD is the collective name for a range of lung conditions including emphysema, chronic bronchitis, and chronic obstructive airways disease. COPD causes a narrowing of the airways and subsequent difficulties in breathing — this is called airflow obstruction. Symptoms include breathlessness, persistent coughing, increased phlegm production and chest infections.
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CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Smoking cessation is the most effective method of slowing the poor respiratory function associated with COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2014). Stopping smoking should be a core tenet of the treatment plan for any patient with COPD, not least because cessation is associated with a 43% decreased risk of hospitalisation (Godtfredsen et al, 2002). It is important that patients realise that abstaining from smoking significantly reduces the risk of exacerbating their COPD symptoms.
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Smoking causes early death from cancer and heart disease, although 36% of all smoking-related deaths are due to respiratory disease (Health and Social Care Information Centre, 2013). In 1997, smoking was responsible for the majority of deaths from lung cancer and chronic obstructive pulmonary disease (COPD), as well as 17% of deaths from pneumonia (Royal College of Physicians, 2000).
It is, therefore, extremely important that people with asthma understand the impact smoking can have on their treatment, the likelihood of hospital admission and the decline in lung function.
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Smoking also causes increased mucous production and a narrowing of the small airways, as well as a decrease in ciliary function (cilla are microscopic, hair-like structures that help to 'sweep' the airways clean of harmful substances) (Ambrose, 2004; NCSCT, 2011). Finally, smoking is linked to decreased immunity, which leads to atherosclerosis and increased risk of infections such as pneumonia, tuberculosis and influenza (Ambrose, 2004; NCSCT, 2011).
symptoms, accelerated decline in lung function and impaired short term therapeutic responses to corticosteroids compared to nonsmokers with asthma — smoking will also increase the clearance of theophylline (drug used for respiratory diseases such as COPD and asthma) from the liver (Thomson and Spears, 2005; Polosa and Thomson, 2012).
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Tobacco smoke also contributes to vasoconstriction and thus increased blood pressure, heart rate and cardiac workload, which reduces oxygen delivery to the tissues (Ambrose, 2004; National Centre for Smoking Cessation and Training [NCSCT], 2011). The subsequent rise in red blood cell production leads to increased blood viscosity, reduced oxygen supply to the body's tissues and potential thrombosis. Reduced oxygenation also decreases the efficacy of radiotherapy treatment and can possibly lead to chemo-insensitivity (Yamashita et al, 2014).
RESPIRATORY TRACT CANCERS Dresler (2003) states that any patients diagnosed with cancer must receive support to give up smoking. Continued smoking after a cancer diagnosis negatively impacts on surgical outcomes as well as affecting the efficacy of radiotherapy and chemotherapy. Mazza et al (2010) suggest that smokers who have cancer should be informed that smoking will impact on survival and that healthcare
professionals should offer smoking cessation advice and support patients with withdrawal symptoms.
ROLE OF THE COMMUNITY NURSE Raising the subject of smoking should be a routine part of any community nursing assessment, but any conversation about smoking should involve far more than simply ticking the 'smoking status' box on the assessment form — it should also encompass the patient's wellbeing and quality of life. The community nurse should be aiming to delay and prevent exacerbation and/or development of any smoking-related disease, as well as ensuring that patients access the best possible support for smoking cessation (temporary or permanent). Essentially, the community nurse's role is to empower patients to make positive choices about their respiratory health — smoking is a major part of this.
Useful interventions
In the most simplistic terms, the community nurse should (National Institute for Health and Care Excellence [NICE], 2006): Ask Advise Act. Asking Initially, the patient should be asked about their smoking status, for
Relvar Ellipta is indicated for patients (≥12 years) uncontrolled on inhaled corticosteroids and as needed short acting beta2-agonists1
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Relvar®▼Ellipta® (fluticasone furoate/ vilanterol [as trifenatate]) Prescribing information (Please consult the full Summary of Product Characteristics (SmPC) before prescribing) Relvar® Ellipta® (fluticasone furoate/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of fluticasone furoate (FF) 100 micrograms (mcg) and vilanterol (VI) 25mcg provides a delivered dose of 92mcg FF and 22mcg VI. Each single inhalation of FF 200mcg and VI 25mcg provides a delivered dose of 184mcg of FF and 22mcg of VI. Indications: Asthma: Regular treatment of asthma in patients ≥12 years and older not adequately controlled on inhaled corticosteroids and ‘’as needed” short-acting inhaled β2-agonists, where a long-acting β2-agonist and inhaled corticosteroid combination is appropriate. COPD: Symptomatic treatment of adults with COPD with a FEV1
