Smoking is one of the biggest preventable causes of premature death in the UK.2 It is linked to a range of serious and often fatal conditions including heart disease and lung cancer.
No Smoking Day is held this month—an important campaign as statistics show that no matter what the patient’s age or how long they have been smoking, almost as soon as they quit, the health benefits begin.2 A recent study found that smokers who quit before the age of 50 years may be able to reverse the risks to the level which non-smokers enjoy. Even those who quit after the age of 60 years reduce the risk of dying by 39%.3
Impact on health
Chronic obstructive pulmonary disease (COPD) is a term referring to two lung diseases, chronic bronchitis and emphysema, that are characterised by obstruction to airflow that interferes with normal breathing. Approximately 900,000 people are currently diagnosed with COPD and it is the fifth biggest killer in the UK.4 NICE reports that COPD accounts for 30,000 UK deaths every year, of which 85% could be attributed to smoking. This is almost double the European average.4
Long-term exposure to lung irritants that damage the lungs and the airways are usually the cause of COPD.5 Cigarette smoke, breathing in second hand smoke, air pollution, chemical fumes or dust from the environment or workplace can all contribute to COPD.
Around half of cigarette smokers develop some airflow obstruction and 10–20% develop clinically significant COPD.6 It is more common in men than women and is associated with socioeconomic deprivation.6 Data from the Health Survey for England show that smokers with COPD tend to be more addicted to cigarettes, but show no greater desire to stop smoking than other smokers.7
CVD is the leading cause of mortality across European countries, accounting for around 1.9 million deaths each year.8 In the UK alone, 159,000 deaths were attributed to CVD in 2011; which included 74,000 deaths from coronary heart disease (an average of 200 people each day) and 42,000 from strokes.9 Although these numbers are falling, CVD remains responsible for more than a quarter of all deaths in men and women.10 The cost of premature death from CVDs, lost productivity, hospital treatment and prescriptions is estimated at £19 billion for the UK.9
Behavioural risk factors are responsible for 80% of all diagnoses of coronary heart disease and cerebrovascular disease.11 Although unhealthy diet, physical inactivity and harmful use of alcohol play a role; by far the leading behavioural risk factor of CVD is smoking. Smoking has been attributed to account for 14% of deaths from heart and circulatory disease12; with the risk being substantially reduced within two years of smoking cessation.13 Compared with non-smokers, smokers have a two to four times increased risk of heart disease and of stroke.14
Smoking is also a major risk factor for peripheral arterial disease (PAD). PAD is a condition in which plaque builds up in the arteries that carry blood to the head, organs, and limbs. People who have PAD are at increased risk for heart disease, heart attack, and stroke.15 PAD is more often found in older people. The NHS estimates that PAD is found in 2.5% of people under 60 years, 8.3% of people aged 60–69 years and 19% of people over 70 years.
Smoking is the most important preventable risk factor for PAD.16 Risks are cumulative, with smokers who also have high blood pressure or have high cholesterol being at the greatest risk. Some types of PAD are almost exclusively found in smokers, with the condition being a rare diagnosis in non-smokers.
Lung cancer is the most common cancer in the world. In the UK, around 39,000 new cases are diagnosed each year and it is estimated that, at any one time, there are 65,000 people living with lung cancer.17
It is known that smokers and ex-smokers have a particularly high risk of developing the disease: although most lung cancers are related to smoking, 10% of people with lung cancer have never smoked. Smokers who smoke between one and 14 cigarettes a day have eight times the risk of getting lung cancer compared to non-smokers. This risk increases the more cigarettes smoked. Although smoking cigarettes is the main cause of lung cancer, pipe and cigar smokers are still more at risk than non-smokers.
However, there are other factors that increase the risk of developing lung cancer disease, for example, exposure to chemicals found in the workplace or environment, such as: asbestos, radon, diesel exhaust fumes, synthetic fibres and many others.17
The risk of lung cancer, like many other cancers, increases steeply with advancing age. The US Surgeon General reports that when smokers quit their risk of getting lung cancer decreases, and that after 10 years an ex-smoker’s risk is about a third to a half that of continuing smokers.18 However, many smokers diagnosed with lung cancer continue to smoke even after treatment, with estimates ranging from 13% to 60%.19
Young women who smoke and have been smoking a pack a day for a decade or more also have a significantly increased risk of developing the most common type of breast cancer. A recent study indicated that an increased risk of breast cancer may be another health risk incurred by young women who smoke.20
The majority of recent studies evaluating the relationship between smoking and breast cancer risk among young women have found that smoking is linked with an increased risk; however, few studies have evaluated risks according to different subtypes of breast cancer.
Smokers should be advised to stop and be offered help and follow-up, with access to a smoking cessation clinic for behavioural support.
NICE recommends focusing particularly on reducing the prevalence of smoking among people in manual groups, ethnic groups and disadvantaged communities. A reminder about the health benefits of smoking cessation and brief advice should be given at every opportunity in primary and secondary care. If appropriate, a referral should be made to the local NHS Stop Smoking Service.3
Opportunities identified by NICE include patients referred for elective surgery and those recently discharged from hospital. Other recommendations include:3
- Offer nicotine replacement therapy (NRT), varenicline or bupropion, as appropriate, to people who are planning to stop smoking
- Pharmacological therapy should normally be prescribed as part of an abstinent-contingent treatment, in which the smoker makes a commitment to stop smoking on or before a particular date (target stop date).
- The prescription of NRT, varenicline or bupropion should be sufficient to last only until two weeks after the target stop date. Normally, this will be after two weeks of NRT therapy and 3–4 weeks for varenicline and bupropion, to allow for the different methods of administration and mode of action.
- Subsequent prescriptions should be given only to people who have demonstrated, on reassessment, that their quit attempt is continuing.
- Consider offering a combination of nicotine patches and another form of NRT (such as gum, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past.
NICE recently also issued guidance to reduce tobacco-related harm for people who don’t feel able to stop smoking in one step.21
The NICE public health guidance is the first in the world to recommend that licensed nicotine-containing products can be used to help people to reduce the amount they smoke, especially those who are highly dependent on nicotine. This also includes people who want to stop smoking without necessarily giving up nicotine, and those who might not be ready to stop but want to reduce the amount they smoke.
It could also encourage more people to consider reducing how much they smoke, with the support of licensed nicotine-containing products (such as nicotine replacement therapy (NRT) patches and gum), and advice from stop smoking services, both of which are proven to be effective.
The NICE recommendations include:
- Organisations responsible for tackling tobacco use, such as stop smoking services and local authorities, should provide public information which highlights that licensed nicotine-containing products are an effective way of reducing the harm from tobacco for both the person smoking and those around them
- Stop smoking advisers and health professionals should advise people to stop smoking in one step, but for those who aren’t ready or are unable to stop in one step, suggest considering a harm-reduction approach
- Advisers and health professionals should offer all types of licensed nicotine-containing products to people who smoke, as part of a harm-reduction strategy, either singly or in combination, according to the individual’s preference and level of dependence. For example, patches could be offered with gum or lozenges. Advise people that using more than one product is more likely to be successful particularly for more dependent smokers
- Advisers should discuss reduction strategies, which may include increasing the time interval between cigarettes, delaying the first cigarette of the day or choosing periods during the day, or specific occasions, when the person will not smoke. Follow up appointments to review progress should also be offered
- Tobacco retailers and retailers of licensed nicotine-containing products should display licensed nicotine-containing products in shops and supermarkets, and on websites selling cigarettes and tobacco products
- Health professionals and advisers should explain to people how to use licensed nicotine-containing products correctly to control cravings, prevent compensatory smoking when trying to stop smoking or reduce the amount they smoke. They should also reassure them that it is better to use these products and reduce the amount they smoke than to continue smoking at their current level
- Advisers should tell people who smoke that some nicotine-containing products (for example, electronic cigarettes and topical gels) are not currently regulated by the Medicines and Healthcare products Regulatory Agency and so their effectiveness, safety and quality can’t be assured. Also advise them that these products are likely to be less harmful than cigarettes.
Smoking cessation is essential for effective prevention of a number of diseases but stopping smoking is not easy. For this reason the latest NICE guidance can help patients take a step wise approach.
1. Smoking statistics, ASH (July 2011). http://www.ash.org.uk/files/documents/ASH_93.pdf Accessed 10/03/14
2. http://www.nosmokingday.org.uk/health-benefits Accessed 10/03/14
3. NICE. Smoking cessation services http://www.nice.org.uk/PH010 Accessed 10/03/14
4. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. http://guidance.nice.org.uk/CG101/Guidance/pdf/English Accessed 10/03/14
5. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Pocket guide to COPD diagnosis, management and prevention Accessed 10/03/14
6. Devereux, G. ABC of chronic obstructive pulmonary disease. Definition, epidemiology and risk factors. BMJ 2006; 332: 1142–44
7. Shahab L, et al. Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample. Thorax 2006; 61: 1043–47
8. European Heart Network and European Society of Cardiology. European Cardiovascular Disease Statistics. September 2013. .
9 Nichols M, Townsend N, Luengo-Fernandez R, et al. European Cardiovascular Disease Statistics 2012.
10. http://www.bhf.org.uk/research/heart-statistics/mortality/time-trends.aspx Accessed 10/03/14
11. Global status report on non-communicable diseases 2010. Geneva, World Health Organization, 2011
12 Health and Social Care Information Centre (HSCIC), Lifestyles Statistics. Statistics on Smoking: England, 2012.
13. Salonen JT. Stopping smoking and long-term mortality after acute myocardial infarction. Br Heart J. 1980;43:463-469.
14. US Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General.
15 https://www.nhlbi.nih.gov/health/health-topics/topics/smo/ Accessed 10/03/14
16. Willigendael EM, Teijink JA, Bartelink ML, et al. Influence of smoking on incidence and prevalence of peripheral arterial disease. J Vasc Surg 2004;40:1158–65
17. http://www.roycastle.org/lung-cancer/Causes-risk-factors-and-symptoms-for-lung-cancer/Lung-cancer-prevention-and-+risk-factors Accessed 10/03/14
18. The Health Benefits of Smoking Cessation – A Report of the Surgeon General. US DHHS, 1990
19 Walker, M et al Smoking relapse during the first year after treatment for early-stage non-small-cell lung cancer. Cancer Epdimiol Biomarkers Prev 2006; 15(12): 2370-7
20. Kawai M, et al. Active smoking and risk of estrogen receptor positive and triple-negative breast cancer among women 20–44 years of age. CANCER 2014; Published Online: 2014 (DOI:10.1002/cncr.28402).
21.http://www.nice.org.uk/PH45 Accessed 10/03/14