A Physiotherapist’s role in tackling smoking addiction and health inequalities
Original Editor - Kristine Antonio, Annie Alexander, Alice Hopkins, Aoife Burke, Rebecca Bonomi and Elizabeth Scaria as part of the Contemporary and Emerging Issues in Physiotherapy Practice
- 1 Introduction
- 2 Physiotherapist's Role in Public Health
- 3 Health Inequality
- 4 Smoking
- 5 Addiction
- 6 Interventions
- 7 Behavioural Support
- 8 Intensive Support Services
- 9 Pharmacotherapy
- 10 Combination Therapy
- 11 Harm-Reduction Approaches
- 12 Pathway for Smoking Cessation
- 13 Conclusion
- 14 References
Cigarette smoking is the leading preventable cause of morbidity and mortality in Scotland. There are approximately 10,000 smoke-related deaths per year. Indeed, people who smoke are putting themselves at risk of heart disease, stroke, cancers and respiratory diseases. It is estimated that one in two of these will die prematurely due to a smoke-related illness. Over the last four decades, smoking prevalence has decreased in Scotland, however it remains one of the nation’s biggest health challenges. Moreover, it is not only the people who smoke themselves that are affected, according to the WHO, 10% of deaths due to tobacco smoking in the world are the result of people being exposed to second-hand smoke.
The need for tackling health inequalities is identified by NHS Health Scotland who state that 34% of adults in the most deprived areas smoke cigarettes as opposed to 9% of those in the least deprived areas. 29.3% of pregnant women in the most deprived areas are current smokers at their first antenatal appointment, significantly higher than 4.5% in the least deprived areas.
Physiotherapist's Role in Public Health
The UK’s Faculty of Public Health defines public health as “The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society”. The Scottish government  provides an understanding of why public health is important. The sustainability of the NHS in 2020-2030 is dependent on improving the health of our ageing population. It is of great importance for NHS service users as there is currently a significant level of avoidable disease that could be affected through the implementation of public health policies. Future generations will also be affected by changes made today within the health care service to allow sustainability of current services. Examples of ways in which improving service users health benefits the economic status of the NHS include reducing GP visits which cost £38, reducing A&E attendance which costs £112 and minimizing the length of hospital stays £2,746.
Chartered Society of Physiotherapy (CSP)  helps to give an understanding of public health and highlights this is a priority for governments within the UK providing the physiotherapy profession with a number of opportunities. It also states that the most up to date public health approach focuses on utilising health promotion to prevent ill health compared to past approaches that focused on managing ill health. This transition is key to the UK health and social care policy. This is backed up by the Scottish government who have derived action 3.4 to be achieved by 2014 that outlines all AHP’s will use every patient contact as an opportunity to improve health and wellbeing and signpost patients to appropriate services.
CSP  identify three main areas of public health;
- Health improvement
- Health protection
- Improving services
Physiotherapists have an important role in all three areas due to the skills and knowledge they possess providing huge opportunities for the profession as a whole. For this to be possible staff must have an understanding of public health and consider the following:
- How they design their services
- How they market their service to patients and local decision makers
- Funding opportunities out with the NHS
- Physiotherapists own practice
The Scottish Government  decided for the first time that they would set the date of 2034 as when they think there will be a tobacco free Scotland. It was decided upon that a smoking prevalence of equal to or less that 5% among the adult population would define a tobacco free Scotland as it is unrealistic to expect everyone to stop smoking. Milestones were set and by 2016 it was predicted that the smoking prevalence should be 17%.
Giving up smoking is the biggest contribution someone can make to improve their health with evidence based smoking cessation support being one of the most cost effective interventions the NHS has available.
In order to achieve a tobacco free Scotland by 2034 smoking cessation services must be the highest quality possible. With reference to the ambitions of the Quality strategy, this means services should be safe and effective but most importantly person centred due to the commitment needed by patients to be successful.
The World Health Organization states health inequality as ‘differences in health status or in the distribution of health determinants between different population groups’. Our health is determined by factors such as difference in lifestyle, incomes, housing, employment and access to health care and other services. In UK, there are significant inequalities in health between different socioeconomic groups. For example, people in lower socio economic groups (see Figure 3 - socioeconomic classification in UK) are more likely to have a chronic ill health and die earlier. These groups are determined by an individual’s occupation, income and educational background. Indicators of inequalities in health outcomes includes:- Healthy life expectancy at birth, low birth weight, premature mortality and mental well being.
Health inequalities also exist between different geographical areas, genders and ethnic groups. The common factor of all these inequalities is that they all link to poverty. In Scotland, on average men living in the most deprived area will die nearly 11 years earlier that those in the least deprived area. Deprived, as defined by the Scottish Index of Multiple Deprivation, means people of low income and people who have fewer resources and opportuities such as education and and health. This reinforces that health inequalities is an evident and long-standing problem in Scotland which is a major concern faced by the Scottish Government.
Geographical inequality is an important factor in determining standards of health. In UK there is a north-south divide and also difference in standards of health within and between areas. In the figure below, it depicts that people from urban and affluent areas do not necessarily present as the least deprived and that people from rural and less affluent areas do not necessarily present as most deprived. For example, Drumchapel and Shettleston(Glasgow) are one of the social and economically deprived areas in UK, (mortality rate 2.3% more than the national average) and yet it is only a short distance from Bearsden, which is one of the wealthiest areas of Scotland. 
Evidence also suggests social factors such as employment status, education and income level has an influence on how healthy a person is. The lower an individual’s socioeconomic status the higher the risk of poor health. The statistical data mentioned in this section, comes from high quality survey and reports conducted by the Scottish Government. However, recent statistical data would be beneficial.
Health Inequalities and Its effects on National Health Service UK (NHS)
It is evidently seen on national surverys and reports that over the past decade health inequality in Scotland is a longstanding issue. In fact, according to a web article by World Socialist Web Site, Scotland's health inequality is the worst in Europe during 2012. Thefore, in order to create a healthier and fairer society it is essential to tackle these health inequalities. According to Marmot(2005) inequality has significant economic impact on the society and a holistic person centred approach is required to reduce inequalities within the populations.
Tackling health inequalities is a challenge since it’s influenced by a wide range of factors such as education, housing, employment, access to health, individual circumstances and their behaviours such as diet, lifestyle, smoking status, alcohol intake and their exercise levels. Due to the size of the issue, tackling and reducing health inequalities is not addressed just by the health services.
Community planning partnerships are responsible for bring all the relevant bodies such as the health department, council (for social care, education, housing, leisure) and voluntary sector together.
Reducing health inequalities will help to increase the life expectancy and improve health in the deprived areas. According to Scottish audit (2002) decreasing the death rate of deprived group in Scotland would bring around ten billion gain to the Scottish economy. Scottish public health observatory has also estimated that one percent reduction in smoking will save around 540 lives per year, Reduction smoking related hospital admissions by 2,300 and hence reducing the estimated NHS spending on smoking related illness by between 13 million and 21 million.
‘Equally well’ report  published in the 2008 highlighted priorities and practical actions required to tackle the widening gap of health inequalities such as
- Smarter Scotland: early years and young people
- Wealthier and Fairer Scotland: Tackling poverty and increasing employment
- Greener Scotland: Physical environments and transport
- Safer and Stronger Scotland: Harms to health and wellbeing: alcohol, drugs and violence
- Healthier Scotland: Health and wellbeing
This report has lead to introduction of major legislations such as ban on smoking in public spaces, minimum pricing for alcohol etc. In order to reduce health inequalities ‘Equally well’ report also highlighted the importance of shifting more resources to early intervention and access to preventative care rather than focusing on the consequences of health inequalities.
Although Scotland has become a world leader in creating public health legislations such as the ban on smoking in public places and minimum unit pricing for alcohol, there has been much less progress in reducing economic and social inequalities. Since income, wealth and power inequalities are the key determinants of health inequalities, it is unlikely that health inequalities will decline if substantial progress on reducing these economic and democratic inequalities are not achieved.The rising income inequalities in recent years are likely to be compounded in the near future by cuts to welfare benefits which will impact on the poorest and most vulnerable groups in Scotland.
Overall, through an extensive literature reviews there was few evidence about effectiveness of interventions based on these polices such as need to tackle childhood obesity, reducing smoking and preventing coronary heart disease, but a further up to date research on wider range of policies and interventions and its effect on health inequalities are required.
According to Macintyre 2007, characteristics of policies more likely to be effective in reducing health inequalities in health includes :-
- Improving accessibility of services such as location, improving public transport links and accessibility of primary care
- Prioritising disadvantaged groups such as the unemployed, homeless, fuel poor
- Offering holistic person centered support such as home visits (if required), face to face or group works, good quality pre school day care
- Starting young such as effective and tailored pre and post natal support and interventions, home visit in infancy and pre school day care
- Reducing price barriers such as free school meals, fruit and milk, free prescriptions, eye tests and smoking cessation therapies.
Despite the vast reductions in mortality in Scotland over the last 150 years, overall life expectancy remains lower, and average mortality remains higher, when compared to the rest of west and central Europe. After reviewing various reports on tackling health inequalities 2008 version is the most up to date and suitable version for this purpose. This highlights the need for further up to date research on policies and its effectiveness.
Please click on the pdf link on “creating a healthier Scotland” report if you would like to know more details on the key findings on experts views on the future of NHS and social care services as well as improving the health and well-being of the population. Creating a healthier Scotland report
Smoking Prevalence in Different Geographical Areas and Socio-Economic Levels
The use of tobacco in Scotland is strongly patterned with deprivation levels. Referring to the graph below regarding the prevalence of smoking from the Scottish Household Survey 2014, 15% of the adults in most deprived areas of Scotland are more likely than those in the rest of the nation to claim that they are current smokers, 34% and 18% respectively.
There is an evident general decreasing trend of the prevalence of smoking with area deprivation. In spite of the similar pattern from the previous year, the prevalence of smoking has decreased in all deprivation quintiles in the last year from 39% to 34% in the 20% most deprived areas. Additionally, the graph below from the Scottish Household Survey Report 2014, depicts the variation of smoking rates by economic status. Almost half of the adults who are permanently ill or disabled or unemployed and seeking work are current smokers. Therefore, this reinforces the evidence that people of a lower socio-economic class (Class 5-7) are more likely exposed to chronic ill health and an earlier death linked to smoking as compared to people of a higher socio-economic class (Class 1-2). With that being said, the data from the Scottish Household Survey Report is based from 2014. It would be more valuable to get a more recent data. However, smoking is a still prevalent issue in Scotland affecting life expectancy and causing health inequality.
A prospective cohort study done by Grueur et al. examined 15,000 people from Renfrewshire and Paisley in Glasgow for 30 years. The data collected showed that the survival of people who have never smoked in the lowest social classes were better than the survival of smokers in the highest of social classes (of the same gender). Furthermore, this studies manifests that smoking appears to be a greater contributing factor to health inequality than social position itself. However, having said that, this study by Gruer et al. was conducted over 30 years and recruited participants between 1972 and 1976. The data would be obsolete in the year 2017 but after extensive literature search, this study is the most suitable for this article. For this reason, this urges a need for an update if smoking is still a great contributing factor to health inequality.
Tackling Health Inequalities Relating to Smoking
Physiotherapists are skilled to address a persons needs in a holistic, patient-centred way. By promoting healthy lifestyle, providing education and counselling in a clinical and cost effective way physiotherapist has a major role in improving health inequalities.
Physiotherapist can address public health improvement in all their interactions by:
- Providing clients with up to date lifestyle advice and signposting to appropriate local services at the appropriate stage.
- Providing prevention classes – highlighting the disadvantages of smoking, also working close with patients cardiac/ pulmonary conditions.
- Working within local organizations and companies to advice on how to improve the health and wellbeing of the workforce.
Allocation of public resources should be according to needs, which aims towards reduction of inequalities. It is also essential to provide our service with additional intensive support, especially for vulnerable groups. Barriers such as accessibility, price, stigma and discrimination should also be avoided.
Despite a push to tackle health inequalities and significant government effort and investment, we still have very little evidence about what interventions actually work. This is in large part due to inadequate evaluation of the policies adopted to address the problem. This stress the need for further research into this area.
Additional information: If you would like to read more about other health professionals role in tackling health inequality please review this PDF link.roleofhealthprofessionals
The book ‘Addiction’ written by Teeson et al.  provides a critical overview of the addictions literature. The authors are experts within these fields and so its content is of high standard. Within this it states that smoking is one of the most common types of addiction, closely following caffeine and alcohol. Nicotine is a highly addictive drug, which is sourced in tobacco leaves, and is one of the main elements in cigarettes. It alters the balance of noradrenaline and dopamine levels in the brain causing changes in mood and concentration which people find enjoyable as they feel it reduces stress and anxiety. However, once you stop smoking the noradrenalin and dopamine levels are altered again, causing increased irritability, stress and anxiety. This leaves the individual in low mood, with poor concentration levels and craving a cigarette to relieve these symptoms.
What is in a Cigarette?
The average cigarette contains over 600 different ingredients on top of over 7,000 chemicals produced by cigarette smoke. Some of these ingredients and chemicals are shown in figure 8.
We may be familiar with some of these harmful ingredients and chemicals such as carbon monoxide, which can be found in car exhaust fumes, or nicotine, also found in insecticides.
Others include formaldehyde, a cancer-causing ingredient of embalming fluid, or cadmium, an active ingredient in batteries, and hexamine, sometimes found in barbecue lighters. Approximately 70 of the chemicals and ingredients found in a cigarette are considered carcinogenic, meaning they have the potential to cause cancer .
Physiological Effects of Smoking
In Sherwood’s  current and relevant 4th edition of the book ‘Essentials of Physiology’ she provides a high quality insight into physiology which helps us understand the physiological effects of smoking as described below.
Cilia are the small, hair-like structures located along our respiratory tract which help keep our airways clear of mucus. The smoke from a single cigarette has the ability to paralyse these cilia for several hours; therefore frequent exposure to this can lead to destruction of cilia. If this occurs and the cilia are unable to clear the constant stream of mucus, it enables inhaled carcinogens to remain in contact with the respiratory airways for prolonged periods. Additionally, cigarette smoke weakens alveolar macrophages while noxious agents in tobacco smoke irritate the mucous linings of the respiratory tract. This results in excess mucus production, which can partially obstruct the airways. When you hear a “Smoker’s cough” this is an attempt to dislodge the excess stationary mucus .
Cigarette smoke can also affect the flow of oxygen within our bodies such that the carbon monoxide attaches to the hemoglobin molecule, which prevents the transport of oxygen through red blood cells. Furthermore, the cyanide impedes tissue’s ability to take up and utilise oxygen. Tissue cannot function without this steady flow of oxygen .
Follow this interactive link to see the affects smoking has on different parts of our bodies in both men and women . This interactive resource provides a very engaging and informative example of how smoking effects our bodies internally and externally. This information is supported by many other physiology resources .
Benefits of Quitting
Figure 9: Benefits of Quitting 
Behavioural Effects of Smoking
Smoking and Mental Health
Smoking rates among people with mental health disorders are significantly higher than the general population, with approximately 3 million of the 10 million people who smoke in the UK being affected with a mental health disorder . Due to this, the NHS spends approximately £720 million per year in primary and secondary care treating smoking-related disease in persons with mental health disorders.
Here is a table which describes mental health disorder prevalence rates and smoking rates within England:
Moreover, people who smoke who have a mental health disorder have a higher mortality rate. The evidence suggests that these rates increase with the severity of the illness . Smoking is also the single largest contributor to their 10-20 years reduced life expectancy . For these reasons, it is important for us as health professionals to gain an understanding on the smoking and mental health relationship, in order to provide effective smoking cessation services to the group involved.
Due to the physiological changes associated with smoking, an individual may experience a wide range of behavioural changes.
In comparison to people who don't smoke or used to smoke, people who smoke tend to be:
- Depressive and anxious
and tend to have characteristics linked to:
- Antisocial or unconventional behaviours 
This research is a literature review of the psychological effects of smoking. Although it covers a wide range of research articles from all over the world, most of these date from the year 2000 or before. In fact, this review therefore highlights the need for further research to be carried out.
The literature highlights evidence that smoking is linked to mental health disorders, notably:
- Panic disorders
- Attention deficit disorder
It is unclear whether poor mental health makes you more likely to initiate smoking, however, some researchers believe that smoking could act as a trigger for a mental health disorder . Indeed, literature has shown that those smoking 15+ cigarettes per day are more likely to have a common mental health disorder than those who smoke fewer or not at all.
A high-quality literature review highlights that it is commonly believed that persons with poor mental health tend to initiate smoking in order to self-medicate , yet another shows this is contradictory to findings as continued smoking has shown to worsen symptoms. However, this article uses evidence relating to an american population and has limited resources, therefore it is difficult to determine how accurate the evidence is. A population-level study carried out in the Netherlands found that people with pre-existing mental health disorders who smoked were at greater risk of developing a mental health disorder . Even though this study had a big sample, the data used was over 10 years old, and therefore it is tough to apply these findings to the british population today. A systematic review found that anxiety or depression may be a factor in starting to smoke , however the quality of this was poor with errors reported after publication, therefore it is not reliable.
Interestingly, a systematic review  found that daily tobacco use is correlated with a higher risk of schizophrenia as well as with an earlier age at onset of psychotic illness. These findings highlight that a smoker is more like to develop the symptoms, however the research was unable to determine the causal link.
Rondina et al.’s study suggests that health professionals should bare these personality traits in mind when promoting smoking cessation in clinical practice. The study emphasises the importance of interdisciplinary work in order for smoking cessation to succeed. Although people with a mental health disorders are less likely to succeed smoking cessation , literature shows that this group of persons are more likely to succeed if they are motivated and given good exterior support, with treatments adapted to the individual  , however the reliability of the responses of patients' included in the study are unknown.
It is important to note that quitting smoking for people with a mental health illness is not associated with a worsening of mental health . In fact, contrarily to thought, a study found that anxiety was reduced after quitting . This is useful information to have as it can be used as a motivator to quit smoking.
Overall, through an extensive literature search, it has been highlighted that there is a lack of in-depth high-quality studies in the area of smoking and mental health in the U.K.. Indeed, further research in this is recommended in order for physiotherapists to have a more relatable understanding of smoking and its relationship with mental health.
Smoking and Stress
In fact, Heishman’s paper highlighted that people who are addicted to smoking felt an increase in stress levels after being deprived of smoking and that people who smoke regularly can even develop these negative moods after a 30-45 minute interval between cigarettes. The study suggests that when these persons believe that their smoking relieves stress, it actually only relieves withdrawal-induced stress and negative moods associated with tobacco deprivation. Effectively, people who smoke who are avoiding smoking are causing themselves added withdrawal stress and so the relief they experience once they smoke is not an effect on their baseline, but simply relieving them from the withdrawal induced stress .
According to literature, there is evidence that people who smoke can adjust their nicotine intake in order to heighten their mental functioning and/or control their mood. This therefore suggests that individuals who do this are at greater risk of dependence and of withdrawal symptoms during smoking cessation.
Indeed, the literature surrounding this are fairly dated, therefore articles should be revised and further research is in order to determine whether these findings are still applicable.
Smoking and Cognitive Performance
According to older studies, evidence has shown that people who smoke show an increase in cognitive abilities. Research suggests that nicotine acts specifically on improving memory scanning and interestingly, the results showed no difference between occasional and regular smokers. However, due to methodological problems and unclarity, the results from the literature are inconclusive.
Lorist and Snel, speculate whether smoking enhances performance by acting directly on the Central Nervous System (CNS) or by relieving symptoms of abstinence. They also consider whether smoking improves performance by affecting specific areas of the brain or if it affects all mental processes.
Indeed, as they suggest, further research in this area is required to ascertain the effects of smoking on cognitive performance.
In recent years there has been a change in the definition of addiction as it was previously described as a behavioural problem with the words “abuse” and “dependency” interlinked with it . However these have been removed and it is now defined by the American Society of Addiction Medicine  as “a chronic, relapsing brain disease that is characterised by compulsive drug seeking and use, despite harmful consequences”. This definition, which has been widely reported in scientific publications and the popular media, was created following four years of reviewing and critiquing the literature along with consulting over 80 experts in the field . Addiction is now viewed as a brain disease due to the addictive substance eg. nicotine, causing the brain to become hyper-responsive to it, thus making it very difficult for the addicted brain to then ignore. The nicotine begins this process, however the changes in the brain persist long after withdrawal from the drug making it difficult to then stop smoking as the brain craves the nicotine.
Stages of Change
It is very common for smokers to go through this cycle quite frequently in their lives and many face relapses following multiple attempts at quitting. However, this is all part of the process of working towards lifelong change . On average it takes smokers 6 attempts at quitting before they successfully give up smoking .
Second Hand Smoking
Second hand smoking (SHS), also known as passive smoking, is the process of breathing in other people’s smoke as well as the smoke from the lit end of the cigarette. The smoke from one cigarette can linger in room for up to 2.5 hours even with a window open.
SHS exposure is associated with a range of adverse physical health issues such as eye and throat irritation, heart disease, respiratory illnesses and cancer . In fact, in 2003, it was estimated that there are 12,200 premature deaths per year in the U.K. due to SHS .
Children are at particular risk SHS effects. Studies have found that they are at greater risk of cot death, glue ear, asthma and other respiratory disease . For these reasons, it is important to promote smoking cessation not only for the person who is smoking’s health, but also for the health of those in close proximity while they are smoking.
Evidence has shown that SHS children or adolescents are susceptible to smoking and have an increased risk of early initiation. Okoli et al.‘ssystematic review has shown that SHS young adults are more likely to associate smoking with positive symptoms, such as dizziness, relaxation and high. It is discussed that for these reasons, children or young adults are more likely to initiate smoking and that SHS hinders smoking cessation. However it is important to note that SHS is difficult to measure accurately, therefore affecting the quality of the studies used in this review. In future, research into SHS should strive to find an accurate measure for SHS.
Smoking Addiction in Young Adults and Children
It is estimated that each year 207,000 children initiate smoking each year in the U.K.. Indeed, smoking is most prevalent in the young adult age group. Over 80% of those report starting smoking before the age of 20 .
There is a wide range of risk factors that can determine the likehood of smoking initiation as a child, such as:
- Parental and sibling smoking
- Ease of obtaining cigarettes
- Friends who smoke
- Socio-economic status
- Exposure to tobacco marketing
- Depictions of smoking in films, tv, etc.
Indeed, as healthcare professionals, it is important that we address the issue of parental or sibling smoking, as children are then 3 times more likely to smoke if their relatives smoke. The data estimated that 23,000 children start smoking due to this.
Studies have shown that young adults tend to believe that health risks associated with smoking will only come later on and therefore adopt the philosophy “I will quit when I’m older”, however this is untrue. In fact, a cross-sectional survey has shown that young adults who smoke believe that they will quit before experiencing any harm, it is also speculated that since it is difficult for them to imagine developing a condition, that knowing the health risks involved with smoking may not encourage smoking cessation. However there was no outcome measure of perceived risk used in this survey (i.e. How likely do you think you will develop lung cancer?) therefore the survey cannot determine whether this is accurate. Furthermore, young adults only consider quitting seriously once the nicotine addiction has set in and therefore find it a lot harder to quit. This therefore justifies the need for a focus of smoking cessation and prevention services on the young adult age group and why the shift from acute to preventative measures is beneficial.
Barriers to Quitting
Large U.K. national surveys have found that a majority of those who smoke want to quit.The most common reasons given for wanting to quit were for health concerns and cost. However a common barrier to quitting smoking, especially amongst women, was weight gain. A cochrane review (a source of high-quality evidence to inform healthcare) looked into the prevention of smoking cessation weight gain and found that exercise and healthy eating were effective strategies. This indeed relates to the role of physiotherapists in health promotion: this is something physiotherapists can therefore pro-actively address when an individual expresses weight gain as a barrier to smoking cessation. Moreover, it is important to note that this weight gain is a minor health risk when compared to continued smoking.
Perceived Barriers to Smoking Cessation
The NSMC conducted a large national qualitative study looking into the people's perceptions of quitting smoking. The focus group study looked at both people who smoke and people who had quit smoking perceived barriers. The research showed that the majority of persons would try quitting without support as a first attempt. The main theme identified by people who smoke for any quit attempt was willpower. However it was identified that they did not realise the extent of their addiction until after failing a first attempt to quit, to then develop an understanding of their addiction and realise they may need external support. The study also highlighted that people who quit smoking engaged with emotional rather than rational or logical benefits of different quitting methods. Finally, the research showed that people who smoke struggled to understand the clear role of the NHS within the quitting process: they realised there are a wide range of services offered to them, however some (such as support groups) were generally viewed as unappealing. Unfortunately, the study abstained to look into what enabled people who had quit to go through the process. This could have been helpful in informing how to improve the current smoking cessation services available in the U.K.. The recommendations state that the NHS should provide a coherent programme rather than a range of methods to quit as well as presenting any relapse as a stepping-stone in their journey to a smoke-free lifestyle.
Perceived Barriers to Smoking Cessation in Selected Vulnerable Groups
When looking at vulnerable groups in the UK, a high-quality systematic review highlighted common barriers in smoking cessation as well as unique barriers to certain groups. The common barriers that were found were the following:
- Smoking for stress management,
- Lack of support from heath or other service providers
- High prevalence and acceptability of smoking in vulnerable communities.
In terms of unique barriers, the following were found:
- Sustaining mental health for persons with mental illnesses
- Cultural differences for indigenous populations
- Living conditions for prisoners
- Competing priorities for homeless persons
- High accessibility of tobacco for high risk youths
All in all, the review underlines that smoking is used as a coping mechanism for daily stresses. These findings as well as the poor quitting success in areas with health inequalities show that smoking cessation interventions need to be tailored to the individual, accessible in the community and within people’s social network.
This research shows that these individuals felt that their smoking is hard to control and were torn between thinking they need intensive measures to quit and that all they really need is strong willpower. They also expressed that they felt marginalised by society and government and that they’re addiction wasn’t regarded as serious as alcohol or drugs. The review also highlights that these individuals were not aware of the extent of services available to them, and regarded the few they knew of as expensive and ineffective, despite evidence to the contrary. The individuals even suggested smoking cessation group services as a motivator for quitting, unaware that these are already available to them.
Another barrier to smoking cessation highlighted by the study’s participants was that it was easier to have access to contraband cigarettes in these deprived areas.
So in future, in order to enable smokers to overcome their addiction, the research showed that we, healthcare professionals, must further promote our smoking cessation services, in a personalised non-judgemental with flexible, low-cost support.
Overall, this review gives us an understanding of the obstacles people who want to quit smoking may face within the U.K as well as within vulnerable groups. It is important for physiotherapists to appreciate these as they may occur in an individual's journey to a smoke-free life. This information also informs our practice and helps us determine which interventions are most suitable to overcome these barriers.
- 9:25-11:29 : Summary of Nicotine Addiction
- 16:08-19:29 : Addiction behaviour and weight gain as a barrier to quitting.
NCSCT state that all health and social care services play a key role in recognising people who smoke and referring them to stop smoking services. This document is of high quality and provides an overvire of the latest evidence relating to the delivery and monitoring of Stop Smoking services. NICE highlights that service providers should aim to treat a minimum of 5% of their local smoking population. This is of importance to health-care professionals as these Qulaity Standards are based on the high quality NICE guidelines which make recommendations for practice. This section of the learning resource will help provide readers with an understanding of their role and what interventions are available to tackle smoking.
NCSCT  states that service design and delivery should be based on the latest evidence highlighted within this document as well as up to date NICE guidelines as these are relevant for all healthcare professionals. Hence the reason that below interventions have been selected as all are recommended within the NICE guidelines identified. These are of high quality as they are based on current evidence and support Physiotherapists to ensure their services are of high quality and best value for money 
Although the most up to date evidence was used throughout this section, it is of importance to note that there is a NICE guideline under development regarding smoking cessation due to be released in November 2017 therefore practice recommendations may change as a result.
NICE  states that training on how to support people to quit smoking is part of the core curriculum for healthcare students across the UK. NICE  highlights that healthcare professionals should ask all patients if they smoke and provide advice on how to stop for those who do. This document is of high quality and provides quality statements drawn from relevant guidelines which provide recommendations for practice to ensure these are met. Below are a few examples of how physiotherapists can do so.
NICE  guidelines encourages the use of brief interventions by health care professionals. This document states this interventions should usually take between five to ten minutes and include at least one of the following;
- Simple opportunistic advice to stop
- Assess patients commitment to stop
- Offer behavioural or pharmacotherapy support
- Provision of self help material and referal to more intensive support such as NHS stop smoking services
These guidelines are of high quality and are directly applicable to health-care professionals woking both within primary care and community settings. Although brief interventions are recommended in practice there are currently still gaps in the literature. One of these being the key characteristics of an effective brief intervention therefore it is important to note that the above provides examples of approaches however does not explicitly state which of these is most effective. This is an area for future research.
NCSCT  idetifies Very brief advice as a quick and effective method in doing so and involves the following three stages;
BMJ (2012) provide a 1-hour online module on very brief advice on smoking in association with the National Centre for Smoking Cessation and Training which can ensure you have the knowlede and skills to deliver very brief advice.
It is important to note that every patient should be given the option of referral to a NHS stop smoking service as this in combination with advise on the best way of quitting is clinically and cost effective and is directly in line with the Making Every Contact count Agenda .
BMJ (2010) provide a 1-hour online module which can help you put NICE guidelines on smoking cessation into practice, this can also be used to continue your professional development.
Although the interventions listed below may not always be implemented by physiotherapists, NICE guidelines recommend all health-care professionals should have an awareness of these services and who is appropriate to refer to them. Therefore this learning resource will now outline a number of the stop smoking interventions on offer in line with Local Stop Smoking services.
Stop smoking services (SSSs) are now well established and play a significant role in helping smokers to stop. It is estimated that in 2012-2013 over 36,000 premature deaths were stopped by these services. This is based on research following 724,247 quit attempts within services in England, the aims of research were to explore the factors that determine longer term abstinence from smoking following intervention by NHS stop smoking services. The study involved secondary analysis of routine data collected by SSSs using the North51 database completed in 2012 and using a prospective study of patients from nine Stop Smoking Services across England examining different types of behavioural support. The different types of behavioural support included closed groups; rolling groups; one to one drop-in; one to one sessions with a specialist advisor and one to one sessions with a sessional advisor such as a practice nurse of pharmacist.
The data showed evidence that at four weeks 373,872 individuals had quit smoking (265,140 were validated using CO). Follow up at 12 months estimated 55,767 individuals had quit. The results are similar UK wide with data for 879,458 quit attempts across services in the UK and of that an estimated 67, 718 individuals had quit at 12 months. All data was attained following evaluating longer-term outcomes from NHS stop smoking services data.
The results should be interpreted with caution as despite the quality of the study certain aspects of the study did have a number of limitations. For example in the secondary analysis several estimates were made including estimates on the number of smokers and populations within the primary care trust (PCT). It was also assumed in the study that smoking declined uniformly by 4% in all PCTs between 2003 and 2005, and also in 2009, when it is in fact unlikely that the smoking rate declined more in PCTs with an affluent population and less in PCTs with a more disadvantaged population. It is important that we recognize this especially given that the nature of this learning resource relates to tackling health inequalities.
However some of the limitations of the secondary analysis were alleviated by the prospective study. These include, for example, certain follow-up data being of lower quality and other aspects of collected data were inconsistent and poorly collected. Yet the prospective study also had its limitations such as recruitment.
Although these results should be looked at with care they do highlight the need for stop smoking services
It is interesting to note that when attempting to quit smoking there are a number of methods that smokers commonly use
- Using nicotine replacement therapy bought over the counter
- Using a stop smoking medicine provided on prescription
- Using stop smoking service (behavioural support plus access to stop smoking medicines)
There are other methods identified by smokers too but we do not have sufficiently strong evidence to support their use.
In many countries the norm to aid smoking cessation involves a combination of behavioural support and medication . Within the United Kingdom the same applies as the support programme offered by Stop Smoking Services involves a combination of behavioural support and licensed pharmacotherapy.
Although it is not of necessity that physiotherapists understand what constitutes behavioural support and behavioural change techniques it has been included in this learning resource to enhance physiotherapists awareness of the different methods that behavioural support can be given. NICE guidelines recommend that everyone who smokes or uses tobacco should be offered behavioural support from a person who has had NCSCT training and supervision. Therefore physiotherapists must be aware of who is appropriate to refer onto this service
Evidence for best practice has shown that a combination of behavioural support from a trained stop smoking practioner and licensed pharmacotherapy can significantly increase a smoker's chances of stopping.
This evidence comes from literature carried out to assess the impact of English treatment services on CO-validated quit rates at 52-week follow up. The data was collected using an observational study method, which was appropriate for this type of research as it allowed for evidence of longer-term cessation rates in users of ‘real world’ smoking treatment services. As opposed to previous literature that has often represented a carefully screened group of individuals who smoke. Within this literature the authors have identified areas for caution within the findings and questioned the use of self-report data.
So What is Behavioural Support?
Behavioural support involves delivering evidence-based behaviour change techniques. It takes the form of advice, discussion, encouragement and activities designed to help quit attempts to be successful.
It increases success rates by
- Helping individuals to abstain, escape from or cope with urges to smoke and to manage withdrawal symptoms
- Maximising motivation to self-restrain and achieve the goal of permanent cessation
- Maximising self confidence
- Boosting self-control
- Optimising the use of pharmacotherapy
The NCSCT training standard recommend that stop smoking practitioners should follow these 3 steps when planning behavioural support:
Research was carried out into the development of a taxonomy of behaviour change techniques (BCTs) used in individual behavioural support for smoking cessation. To identify whether a functional higher order classification of BCTs could be applied. Prior to this research there was no way of establishing which of these BCTs were most effective as BCTs that had been evaluated in the past had not been systematically labelled. As well as this the lack of reliable taxonomy of BCTs hampers advances in treatment, as a basis for specifying what smoking cessation practioners should be doing in their sessions with patients cannot be provided. This learning resource will therefore use the research that was carried out to display the wide variety of behavioural support methods.
Behaviour Change Techniques (BCTs)
As previously mentioned the NCSCT recommend using BCTs to deliver behavioural support. BCTs were defined as “any explicit description of intervention content that can alter a participants' smoking behaviour e.g. not including mode or style of delivery". There is an extensive table within this piece of work which lists forty-four different BCTs categorised according to function but rather than display this table this learning resource will break down BCTs into different functions.
The overall aim of BCTs is to change the balance of impulses and inhibitions by reducing impulses to smoke and increasing motivation and capacity to resist those impulses on all relevant occasions.
Using data from the English Stop Smoking Services they classified BCTs into four functions:
Examples of BCTs That Focus on Behaviour and Addressing Motivation
- Provide information on consequences of smoking and smoking cessation
- Boost motivation and self-efficacy
- Provide feedback on current behaviour. This involves providing feedback from assessment of current self-reported or objectively monitored behaviour.
- Rewards 3 on successfully stopping smoking
- Provide normative information about others’ behaviour and experiences. This involves giving information about how the individuals experience compares with other smokers experiences.
- Prompt commitment from the client there and then. This involves encouraging the smoker to affirm or reaffirm a strong commitment with the programme of quitting smoking.
- Strengthen ex-smoker identity. This can involve a variety of factors such as encouraging the smoker to re-assess the attraction to smoking.
- Identify reasons for wanting/not wanting to stop
- Explain the importance of abrupt cessation. Involves explaining the importance of why it is better than cutting down gradually if possible.
- Measure expired-air carbon monoxide concentration
BCTs That Work to Maximise Skills and Capacity for Self-Control Include
- Facilitate barrier identification and problem solving. Involves helping the individual to identify general barriers such as susceptibility to stress that may make it harder to stay off cigarettes and develop general ways of addressing these.
- Facilitate relapse prevention and coping
- Facilitate action planning/develop treatment plan
- Facilitate goal setting
- Prompt review of goals
- Prompt self-recording. Involves helping the individual to establish a routine of recording information that could be useful such as identifying situations or times when urges are strong or not as strong
- Advise on changing routine to lessen exposure to smoking cues
- Advise on environmental restructuring again to lessen exposure to smoking cues
- Set graded tasks. Involves working with the individual to create small achievable goals.
- Advice on conserving mental resources. Involves giving advice on minimising stress and other demands.
- Advice on dodging social cues for smoking. This involves giving specific advice on how to avert being exposed to social cues for smoking
Classifying BCTs by Function
|Directly Targeted at behaviour change||Not Directly targeted at behaviour|
|Focus on specific behaviour- address motivation|| Promote adjuvant activities;|
1. Advice on stop-smoking medication
2. Advice on/facilitate use of social support
3. Adopt appropriate local procedures to ensure clients obtain free medication
4. Ask about experiences of stop smoking medication
5. Give options for additional/later support
|Focus on specific behaviour- maximise self-regulation|| General aspects of intervention|
1. Tailor interactions appropriately
2. Emphasise choice
| General aspects of interaction- focusing on information gathering|
1. Assess current and past smoking behaviour
2. Assess current readiness and ability to quit
3. Assess past history of quit attempts
4. Assess withdrawal symptoms
| General aspects of interaction- focusing on general communication|
1. Build general rapport
2. Evoke and answer Questions
3. Explain the purpose of CO monitoring
4. Explain expectations regarding treatment programme involves explaining the requirements of the individual
5. offer and direct individuals towards appropriate written resources
6. Provide information on withdrawal symptoms
7. Use reflective listening
8. Evoke client views
9. Summarise information and establish a clear confirmation of decisions and commitments made
10. Provide reassurance
It can be concluded that although the National Centre for Smoking Cessation and Training may not refer to every form of BCT described in this learning resource the delivery of behavioural support for the NCSCT Training standard does correlate as the methods of behavioural support are classified into the same functions of directly addressing motivation in relation to smoking and smoking cessation; maximizing capacity for skills for exercising self-control; promoting effective medication use and supporting other activities and general aspects of communication.
From the results of this research a taxonomy of BCTs used for individual behavioural support for smoking cessation was developed and it was found to be reliable to code the treatment manuals of Stop Smoking Services in England. As well as this a higher-order functional classification was also developed and this could be reliably applied to the BCTs.
Positives to this study include an attempt to reduce potential observer bias and the amount of interpretation required by keeping the language as similar as possible to the original descriptions. Meaning that the BCTs varied considerably in terms of breadth and specificity, with some BCTs listed in the taxonomy the same as those for interventions to increase physical activity and healthy eating. However, one limitation to this study is that the list of BCTs identified and analysed used guidance documents and treatment manuals from just one country, England. In the future it is possible that different techniques may be used in other contexts or added.
Finally, this study was only a starting point in the labelling and classification of BCTs for smoking cessation and it should be recognised that the value of this exercise is dependent on there being sufficient homogeneity within the content of the BCTs for these to form useful constructs in predicting the success of behavioural interventions. However, the results are useful as twelve of the BCTs listed in the taxonomy were the same as those for interventions aimed at increasing physical activity and healthy eating suggesting that it may be feasible to develop a set of BCTs using a common language to describe interventions across a range of health-related behaviours.
Please refer to the NCSCT Training Standard: Learning Outcomes for Training Stop Smoking Practitioners for a detailed account of the delivery of behavioural support.
Intensive Support Services
NICE  state that health care professionals (HCP's) should refer people who smoke to intensive support services within the NHS. For example, NHS stop smoking services. The findings within this document are of high quality and are appropriate for all physiotherapists working within primary care and community settings. However, a number of gaps in the current evidence base are identified therefore it is important to note that not all the recommendations are backed up by the same level of evidence.
NHS  outlines what NHS stop smoking services involve as follows;
Anyone who lives in the United Kingdom is entitled to NHS stop smoking services and can either be referred by professionals they come in contact with in the healthcare system or by simply phoning their local service to make an appointment.
The service is run by trained professionals who provide a combination of evidence based support and treatment to give the best chance of stopping smoking. NICE  backs this up by stating a combination of behavioural support and pharmacotherapy give people who smoke the best chance of successfully stopping. The service also provides access to stop smoking aids at the normal price of prescriptions. Dependent on location a mixture of one to one, group and drop in sessions are available.
- Weeks 1-4 - weekly contacts with your advisor either over the phone or face to face
- Weeks 5-12 - contacts are less frequent.
- An emergency out of hours number is also provided to help limit the chance of relapse
In 2015/2016 around 7% of the estimated 932,000 adult smokers in Scotland made a quit attempt with NHS smoking cessation services. One month after quit dates, 37% reported they still weren’t smoking and 22% by three months. Of the people who reported they still weren’t smoking one month after, 65% were confirmed by carbon monoxide testing indicating a true quit rate of 24% rather than 37% . This report provides reach and quit success of NHS smoking cessation services in Scotland for 2015/2016. One limitation of these statistics is that total quit attempts was recorded rather than total number of clients with a quit attempt therefore the results may have been affected by this.
The NICE guidelines recommend that smoking cessation advisers and healthcare professionals may recommend and prescribe stop smoking medicines as an aid to help people to quit smoking, along with giving advice, encouragement and support, or referral to a smoking cessation service. Individuals seeking support to stop smoking should be offered a full course of the pharmacotherapy they choose as this acts as an aid to help people stop smoking and by taking the full course increases chances of success. Pharmacotherapy should also be offered to patients who refuse referral to intensive support services.
The different types of pharmacotherapy on offer are:
• Champix tablets (varenicline)
• Zyban tablets (bupropion)
• Nicotine Replacement Therapy (NRT), including patches, gum, lozenges, microtabs, inhalators and nasal sprays 
The guidelines state that before prescribing treatment advisers consider the person's intention and motivation to quit and how likely it is that they will follow the course of treatment. Advisers should also consider the individuals preference of treatment, whether they have attempted to stop before (and how), and if there are medical reasons why they should not be prescribed particular pharmacotherapies.
These medications 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 known as the target stop date. These stop smoking medicines 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 three to four weeks for varenicline or bupropion, to allow for the different methods of administration and mode of action. Future prescriptions should be given only to people who have demonstrated on re-assessment, that their quit attempt is continuing.
This information comes from NICE public health guidance and the recommendations outlined were arrived at following careful consideration of the available evidence. As health professinal these clinical guidelines recommend how we should care for people with specific conditions.
There is evidence to support all methods of pharmacotherapy. For example, all of the readily available forms of NRT can help people who make a quit attempt to increase their chances of successfully stopping smoking as NRTs increase the rate of quitting by 50-70%, regardless of setting.
Combination therapy refers to using a number of NRT products. This type of therapy has been shown to have an advantage over using just one product, increasing the chances of quitting by up to 35%. It is another method considered to be cost-effective and is readily available as part of standard treatment.
It is suggested that a nicotine patch is used to help with ‘background’ urges to smoke, combined with a faster-acting product such as mouth spray or lozenge to top up the dose of nicotine and to assist with ‘breakthrough’ urges to smoke.
NICE guidelines recommend to consider offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, 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.
It was research carried out by the Cochrane Collaboration that identified that combination therapy has shown to have an advantage over using just one product. Therefore this evidence is of high quality as Cochrane reviews are internationally recognised as the highest standard in evidence-based health care resources. The decision was made to refer to such reviews as they are of the most up-to-date and reliable evidence.
NICE  guidelines identifies that people who are unwilling or not ready to stop should be offered a harm-reduction approach to treatment.
It states that people who are unwilling or not ready to stop includes people who;
• May not be able to or don’t want to stop smoking in one step
• May want to stop smoking without giving up nicotine
• May not be at the stage they want to stop smoking completely but want to reduce the amount they smoke
This same document outlines why this is important for physiotherapists. It highlights that all health-care professionals must make sure they have a clear understanding in order to explain harm-reduction approaches and offer them to people unwilling or not ready to stop smoking while still maintaining stopping smoking as the best approach.
What’s included in harm-reduction approaches to smoking is identified as follows;
- Stopping smoking with the help of at least one licensed nicotine containing products for as long as necessary in order to prevent relapse
- Cutting down with the aim of quitting with or without the use of licensed nicotine containing products
- Reducing the number of cigarettes smoked with or without the use of licensed nicotine containing products
- Temporary abstinence from smoking with or without the use of licensed nicotine containing products
This NICE guideline is appropriate for all health-care professionals working within the NHS to refer to. However, it doesn't cover pregnant women or maternity services therefore physiotherapists must seek the appropriate guidelines if working with these clinical populations . Although of high quality it does highlight that there is currently limited evidence to show the long-term health benefits from adopting a harm reduction approach to smoking or how this intervention compares to stopping smoking in terms of health benefits. This is an area for development within the evidence base and is something to be aware of.
NHS  backs this up by highlighting there is currently limited evidence regarding the effectiveness of a harm reduction approach to smoking cessation when the person involved has no intention to quit. There is some preliminary evidence that those who reduce the amount they smoke are more likely to to go on to quit, especially if licensed nicotine containing products were used throughout the process. This is an area for future research which will help justify the use of this approach by physiotherapists. The information within this document is of unknown quality and again refers to the general population and not pregnant women or those planning pregnancy.
Unlicensed Nicotine Containing Products
NICE  highlights that a number of nicotine containing products are currently not regulated by the Medicines and Healthcare products Regulatory Agency (MHRA) therefore are not available within the NHS as their effectiveness and safety are unknown. E-cigarettes are one example even though they are likely to be less harmful than cigarettes due to absence of tobacco. This same document states that those products that are currently being marketed need a medicines license once the European Commissions revised Tobacco Products Directive comes into effect which was due in 2016.
NCSCT identifies a number of interventions that are not recommended for practice within the NHS as follows;
- Some evidence of effectiveness but not recommended
- Rapid smoking
- Insufficient evidence: not recommended
- Allen Carr
- St John’s Wort
- Evidence of effectiveness: not recommended
- Laser therapy
Although these two pieces of evidence are a number of years old and there may have been changes since, there is currently no new guidelines to recommend practice should change as of yet.
Pathway for Smoking Cessation
Health inequalities in Scotland remain a prevalent and current issue faced by the Scottish Government due to disparity in deprivation and socio-economic levels. In the light of these factors, they are correlated to the prevalence of smoking as mentioned in this resource. It is clear in this work that smoking has many negative health repercussions. The various detrimental physiological and behavioural effects of smoking on health make it imperative that smoking is to be stopped. With the several interventions mentioned above, we can adapt this in our role as physiotherapists to help tackle smoking and nip it in the butt.
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