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The 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.

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.

Smoking and respiratory disease: the role of the community nurse

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).

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).

Camilla Peterken, smoking cessation specialist,service development, training and change management specialist, the Nyvej Partnership

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.

KEYWORDS:COPD Smoking Respiratory disease Screening

Camilla Peterken

EFFECTS OF SMOKING

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.

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 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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Stopped SmokingStarted pLaYing

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

nicotine

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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).

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).

Deaths from smokingSmoking 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).

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 asthma-related admissions to hospital (Purdy et al, 2011). Active smokers will experience more severe asthma

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 interventionsIn the most simplistic terms, the community nurse should (National Institute for Health and Care Excellence [NICE], 2006): Ask Advise Act.

AskingInitially, the patient should be asked about their smoking status, for

symptoms, accelerated decline in lung function and impaired short term therapeutic responses to corticosteroids compared to non-smokers 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).

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.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

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.

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.

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

Red Flag Persistent cough

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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Relvar Ellipta is indicated for patients (≥12 years) uncontrolled on inhaled corticosteroids and as needed short acting beta2-agonists1

Because I simply

for asthmadon't have space

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<70% predicted normal (post-bronchodilator) and an exacerbation history despite regular bronchodilator therapy. Dosage and administration: Inhalation only. Asthma: Adults and adolescents ≥12 years: one inhalation once daily of: Relvar 92/22mcg for patients who require a low to mid dose of inhaled corticosteroid in combination with a long-acting β2-agonist. If patients are inadequately controlled then the dose can be increased to one inhalation once daily Relvar 184/22mcg. Relvar 184/22mcg can also be considered for patients who require a higher dose of inhaled corticosteroid in combination with a long-acting β2-agonist. Regularly review patients and reduce dose to lowest that maintains effective symptom control. COPD: one inhalation once daily of Relvar 92/22mcg. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate & magnesium stearate). Precautions: Pulmonary tuberculosis, severe cardiovascular disorders, chronic or untreated infections, diabetes mellitus. Paradoxical bronchospasm – substitute alternative therapy if necessary. In patients with hepatic with moderate to severe impairment 92/22mcg dose should be used. Acute symptoms: Not for acute symptoms, use short-acting inhaled bronchodilator. Warn patients to seek medical advice if short-acting inhaled bronchodilator

use increases. Therapy should not be abruptly stopped without physician supervision due to risk of symptom recurrence. Asthma-related adverse events and exacerbations may occur during treatment. Patients should continue treatment but seek medical advice if asthma symptoms remain uncontrolled or worsen after initiation of Relvar. Systemic effects: Systemic effects of inhaled corticosteroids may occur, particularly at high doses for long periods, but much less likely than with oral corticosteroids. Possible Systemic effects include: Cushing’s syndrome, Cushingoid features, adrenal suppression, decrease in bone mineral density, growth retardation in children and adolescents, cataract, glaucoma. More rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). Increased incidence of pneumonia has been observed in patients with COPD receiving Relvar. Risk factors for pneumonia include: current smokers, patients with a history of prior pneumonia, patients with a body mass index <25 kg/m2 and patients with a FEV1<50% predicted. If pneumonia occurs with Relvar treatment should be re-evaluated. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take Relvar. Interactions with other medicinal products: Interaction studies have only been performed in adults. Avoid β-blockers. Caution is advised when co-administering with strong CYP 3A4 inhibitors (e.g. ketoconazole, ritonavir). Concomitant administration of other sympathomimetic medicinal products may potentiate the adverse reactions of FF/VI. Relvar should not be used in conjunction with other long-acting β2-adrenergic agonists or medicinal products containing long-acting β2-adrenergic agonists. Pregnancy and breast-feeding: Experience limited. Balance risks against benefits. Side effects: Very Common (≥1/10): Headache, nasopharyngitis. Common (≥1/100 to <1/10): Candidiasis of the mouth and throat, dysphonia, pneumonia, bronchitis, upper respiratory tract infection, influenza, oropharyngeal pain, sinusitis, pharyngitis, rhinitis, cough, abdominal pain, arthralgia, back pain, fractures, pyrexia. Uncommon (≥1/1,000 to <1/100): Extrasystoles. Legal category: POM. Presentation

and Basic NHS cost: Relvar® Ellipta®. 1 inhaler x 30 doses. Relvar Ellipta 92/22 - £27.80. Relvar Ellipta 184/22 - £38.87. Marketing authorisation (MA) nos. 92/22mcg 1x30 doses [EU/1/13/886/002]; 184/22mcg 1x30 doses [EU/1/13/886/005]. MA holder: Glaxo Group Ltd, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK. Last date of revision: November 2013. Relvar® and Ellipta® are registered trademarks of the GlaxoSmithKline group of companies. All rights reserved. Relvar® Ellipta® was developed in collaboration with Theravance,Inc.

Adverse events should be reported. For the UK, reporting forms and information can be found at www.mhra.gov.uk/yellowcard. For Ireland, adverse events should be reported directly to the IMB; Pharmacovigilance Section, Irish Medicines Board, Kevin O’Malley House, Earlsfort Centre, Earlsfort Terrace, Dublin 2, Tel: +353 1 6764971. Adverse events should also be reported to GlaxoSmithKline on 0800 221 441 in the UK or 1800 244 255 in Ireland.

References: 1. Relvar Ellipta (92/22 mcg) Summary of Product Character-istics, GlaxoSmithKline (accessed July 2014). 2. Relvar Ellipta (184/22 mcg) Summary of Product Characteristics, GlaxoSmithKline (accessed July 2014). 3. Bleecker ER et al. Fluticasone furoate/vilanterol 100/25mcg compared with fluticasone furoate 100mcg in asthma: a randomized trial. JACI In Practice 2014 (in press). 4. Svedsater H et al. Ease of the Ellipta dry powder inhaler: data from three randomised controlled trails in patients with asthma. Primary Care Respiratory Medicine 24. Article 14019. Doi: 10.1038/npjpcrm.2014.19 (pub online 26th June 2014).

UK/FFT/0367/14 Date of preparation: July 2014

The first ICS/LABA combination to deliver continuous 24-hour efficacy in a practical, once-daily dose1-3

Delivered in a straightforward device4

That offers value to the NHS

Relvar is generally well-tolerated in asthma1,2

Practical efficacy

®®

Asthma

www.relvar.co.uk

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function. Patients should be reassured that measures like NRT and expert support do work — in fact, people are four times more likely to give up smoking with this kind of support than on their own (Kanner et al, 1999). Also, it should be stressed that services can be provided near to where they live or by phone if they are housebound.

ActionNurses can act by organising a referral to their local NHS 'stop smoking' service and making sure that, if the patient has been using NRT while in hospital for example, they have repeat prescriptions.

It is also important to simply check with patients how they are doing at each visit and to encourage them to notice any changes to their health as a result of reducing or stopping smoking.

How to work with patientsWhen approaching smoking cessation,

Table 1: Bringing up smoking as part of a patient consultation

When the community nurse is seeing a patient regularly this is an ideal opportunity to bring his or her smoking habits into the conversation. A typical conversation might go like this:

Nurse: ‘What have you heard about smoking and COPD? ‘ — finding out what the patient knows

Patient: ‘I know it’s no good for me, the doctor keeps bringing it up...’

Nurse: ‘It sounds like you understand it doesn’t help your COPD?’ —reflective listening and affirmation

Patient: ‘But what’s the point? We can’t turn the clock back can we?’

Nurse: ‘You don’t feel it’s worth it?’ — reflecting meaning

Patient: ‘Not really.’

Nurse: ‘I can understand that, and we can’t reverse the damage, but giving up smoking could make a real difference to the amount of oxygen you receive on a daily basis and that can happen quite quickly. You could also find you don’t need to get admitted to hospital quite so often?' — providing relevant information in the ‘here and now’

Patient: ‘Well, that would be good. I seem to go back to hospital every few months and each time it's worse.’

Nurse: ‘So would that be a reason to have a go at quitting? Would you like me to refer you to the local stop smoking service? They can offer you free support over the phone if you don’t feel up to going to see them and they can provide medication such as nicotine patches?’

In this conversation the patient is enabled to consider the control they might have and to express both their concerns and their reasons for quitting. Finally, the community nurse is able to make sure the patient knows that effective free services do exist.

it can be helpful for the nurse to see it as a crucial part of patients' care and treatment, rather than as ‘health promotion’ — this can legitimise smoking cessation and gives it a greater sense of importance.

Also, community nurses should remember that patients may feel guilty and embarrassed about smoking, regarding it as a 'dirty habit'. It is important to show interest, but to remain emotionally detached — patients should not be giving up smoking to please the nurse, but rather to help themselves. Also, it is more likely that patients will provide an honest and open assessment of their smoking status if they view the nurse as a healthcare professional first, rather than as a 'confidant'.

Always remember that patients are dealing with a difficult addiction and a set of ritual behaviour that may have been part of their lives for many years. They may have real concerns about failing and how they will cope without smoking and for many — especially those who are isolated, lonely and bored at home — smoking will represent a regular break in the day-to-day monotony. Nurses should listen to patients and explore what smoking means to them — in this way they will be better able to tailor smoking cessation advice so that it is relevant to the patient's particular situation.

Tips for bringing up smokingIt can sometimes be difficult for community nurses to know what to say once they have asked a patient if he or she smokes, especially if the patient appears resistant. Using motivational interviewing principles and skills, such as reflective listening and affirmation, can support them in continuing the conversation about smoking (Miller and Rollnick, 1991). An example of a typical smoking cessation conversation using these techniques is shown in Table 1.

Brief interventions.The community nurse can also play an important role in smoking cessation by using some relatively brief interventions:Bring smoking into the

conversation at regular intervalsProvide information relevant to

example, what do they know and understand about smoking and their condition? How would they feel about quitting? If they have recently been an inpatient, how did they cope with not smoking? It is also useful to find out if the patient used any measures such as nicotine replacement therapy (NRT) (i.e. patches), and if they would like to carry on? The nurse can also ask if the patient might be willing to try temporary abstinence while having treatment, even if they cannot face quitting for good. Patients do not always need more information, but they often need to understand more about the link between smoking and their condition.

AdviceCommunity nurses should advise the patient that stopping smoking is one of the most important steps that they can take to improve their respiratory and general health and that it is never too late to improve their respiratory

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the patient’s condition (such as cessation leaflets) and talk about the short and long-term benefits of cessation

Help the patient understand the link between smoking and any respiratory condition, especially how the illness may have developed, how it is exacerbated and the efficacy of treatment

Organise a referral and make sure the patient has access to pharmacotherapies, such as NRT

Provide positive feedback on any improvements in the patient's condition.

What should the patient expect from treatment?Smoking cessation services funded by the NHS are available throughout the country. Community nurses can refer patients to these either by phone or fax, or often digitally. Treatment is offered either in one-to-one sessions or in groups run at clinics, GP surgeries, hospitals, pharmacies, community venues or sometimes over the phone.

Smoking cessation programmes typically provide a six- to seven-week programme of support, including pharmacological treatments like NRT or drugs like varenicline (marketed as Champix® in the UK), alongside behavioural support to help patients plan for life without smoking — this usually includes identifying improvements to their health and monitoring their cessation through carbon monoxide measuring (using a small hand-held device that measures the amount carbon monoxide as the patient exhales), as well as relapse prevention.

CONCLUSION

Smoking has long been linked with respiratory disease and is a recognised risk factor for COPD, asthma, lung cancer and interstitial lung disease. Community nurses are tasked with improving the quality of life for people living at home with long-term conditions and, for many, smoking is a large part of this, affecting the healing and maintenance of many respiratory conditions.

Community nurses can make a valuable contribution to the health of people who smoke by helping them to improve their quality of life and avoid admission by stopping smoking. This article has looked at a range of interventions that will help community nurses communicate with their patients around smoking, as well providing a few pointers as to how patients can be supported if they decide to give up. JCN

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Mazza R, Lins M, Boffi R, Invernizzi C, De Marco C, Perotti M (2010) Taking care of smoker cancer patients: a review and some recommendations. Ann Oncol 21(7): 1404–09

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