Smoking cessation and management of patients with asthma

Key Points:

• Tobacco smoke can be mainstream, side stream or second hand, all of which have a severely negative impact upon asthma symptoms
• Smoking remains the single biggest cause of premature mortality in the UK
• Shisha (waterpipe) use is dangerous. Every hour of shisha use is equivalent to smoking 100 cigarettes

Tobacco smoking by the individual causes chemical smoke to enter the lungs, and then chemicals to enter the bloodstream and body tissues. This is known as ‘mainstream smoke’. While much of it is absorbed by the smoker, some is exhaled. While the cigarette, pipe or cigar is lit, the burning end also expels smoke and chemicals, known as ‘sidestream smoke’. ‘Second-hand smoke’ is a combination of both sidestream and exhaled mainstream smoke, and affects both the smoker and non-smokers in the area. Tobacco smoke contains more than 7,000 chemical compounds, present as either gases or as tiny particles.¹ These include carbon monoxide, arsenic, formaldehyde, cyanide, benzene, toluene and acrolein. Carbon monoxide reduces the capacity of red blood cells to circulate oxygen.

Smoking remains the single biggest cause of premature mortality in the UK, accountable for more deaths per year than the next six modifiable causes of premature mortality.^2-6 One adult smoker in two will die as a consequence of tobacco smoking, losing an average 10 years of life.⁷ Although smoking rates have considerably reduced over the last few decades, it is still the case that around 19% of adults smoke daily,7 around 9.5 million people, and there are higher rates of smoking in more vulnerable populations. Accurate prevalence figures for adult smokers with asthma are not available for the UK, but international estimates in developed countries suggest 20-25% of asthma patients also smoke,⁸ and it has been suggested that children and adolescents with asthma are more likely to be smokers.⁹

For every smoker who dies, 20 are suffering from a smoking-related disease.⁷ Respiratory diseases for both smokers and non-smokers (as a consequence of second-hand smoke exposure) are, unsurprisingly, a key element of this.

Tobacco smoking has been identified as a causal factor in the development of asthma¹⁰ – the likelihood of becoming asthmatic is increased by:¹⁰

• Maternal smoking in pregnancy – children born to mothers who smoked while the baby was in utero are more likely to develop childhood asthma.
• Parental smoking (especially for children, although it increases the risk for later development too).
• Exposure to second-hand smoke.
• Smoking

Tobacco smoke is also a significant trigger for an exacerbation of asthma, in both children and adults. Either mainstream or second-hand exposure increases the likelihood of an asthma attack – an adult with asthma at a party in an enclosed space with significant exposure to second-hand smoke will quickly experience symptoms.¹¹

For pediatric exposure, babies and small children exposed to tobacco smoke are more likely to have respiratory infections and wheeze, and are more likely to go on to develop asthma as they get older. Older children diagnosed with asthma or being treated for asthma are at a high risk of smoke triggering asthma symptoms or an asthma attack.¹⁰

Electronic cigarettes (‘vapes’) are non-combusting, usually battery-operated devices that deliver nicotine via a heated liquid, in a water-based gas form (similar to steam). The nicotine enters the bloodstream in the same way that nicotine in smoked tobacco does (via the lungs), but without the extra chemicals that come via combustion.

There is currently limited quality and quantity evidence about the impact of electronic cigarettes on pulmonary function, but it is likely to be significantly better than smoking. It has been suggested that12 as there are some impacts on the lungs from the use of electronic cigarettes, they are probably not quite as safe as the current licensed medications, although this is difficult to quantify. Until more information is available, it is safest to advise patients with asthma to avoid inhaling anything that may irritate the lungs, with total cessation being the best option.

Shisha, water pipes, or hubble bubble, heat tobacco and add it to flavored steam before inhalation. Water pipes have a similar risk profile to standard smoking, with an hour of use delivering about the same levels of toxin exposure as smoking 100 cigarettes. Second-hand exposure is similar to standard second-hand tobacco smoke exposure.¹³

There are some key actions nurses can take with patients to reduce the impact of smoking on asthma in the community:

1. Supporting effective smoking cessation.
2. Supporting behavioral change towards smoke-free homes and cars.
3. Supporting smoke-free pregnancies.
4. Providing accurate information to children and adults with asthma.
5. Helping parents and family members who smoke to stop completely, or avoid smoking anywhere near family members with asthma.

Supporting effective smoking cessation

Stopping smoking is the single most effective action people can take to reduce the burden of smoking on asthma. All nurses should undertake the National Centre for Smoking Cessation (NCSCT) (see Resources) Very Brief Advice (VBA) free, open access, on-line training course. This covers an effective 30-second approach to promoting effective cessation, aligned to the PH1 National Institute for Health and Care Excellence (NICE) guidance on smoking brief intervention and referral¹⁴ and smoking pathway:¹⁵

Ask – all patients if they have smoked at all, even a puff, in the last seven days. Advise – all patients that:

– The best thing they can do for their health, wealth and wellbeing is to stop smoking completely.

– The best way to achieve this is with an eight to 12-week multi structured program of behavioral change techniques, with a trained stop smoking advisor (registered on the national NCSCT practitioner register (see Resources), including evidence-based and licensed medication (nicotine replacement therapy – NRT, Bupropion – Zyban and Varenicline – Champix).

– The best initial option is for the patient to have a discussion with a trained advisor, who can talk them through the pros and cons of the above approach, and can offer alternative approaches. Cold turkey and no-treatment approaches deliver around 4-5% long-term quit rates, compared to the multi structured approach with medication that will deliver 20-25% long-term quit rates.

Act – make an electronic referral to the local stop smoking service or begin treatment.

Smoke-free homes and cars

Many smokers have made changes in their smoking behaviors in the home. However, there remains a belief that opening windows or confining smoking to only one room is an effective mechanism for reducing others’ exposure to second-hand smoke. Unfortunately, this belief is unfounded. Opening windows can create a vacuum that sucks odorless toxins further into the home. The only way to create a smoke-free home or car is not to smoke in the closed environment at all. All nurses should take the smoke-free homes and cars brief advice training program (see Resources), which is free and open access.

Smokers should be advised to step outside of the closed environment (home or car) before smoking and to move away from doors and windows before lighting up. Asthma patients who may be visited by smokers should be encouraged to tell everyone that their home is smoke free. If available, fridge magnets and stickers could be provided for use in the home. Asthma patients should be encouraged to feel comfortable asking people to not smoke near them, or in a closed environment that they are sharing.

The recent legislation on not smoking in cars where children are present can also be used as a lever for discussion. Again, if possible, car magnets and air fresheners may be available from the local stop smoking service, which can be found using the postcode search facility (see Resources).

Smoke-free pregnancy

All pregnant women should be encouraged by all healthcare professionals at every contact to remain smoke free themselves through their pregnancy, and to feel comfortable to ask those who live with them to refrain from exposing them to second-hand smoke. A new training program for very brief advice and intervention on smoking in pregnancy is available on the NCSCT website (see Resources). Patients can be referred to the local stop smoking service, which should offer advice on creating a smoke-free environment.

Providing accurate information to children and adults with asthma

All healthcare professionals should provide clear and accurate information to children and adults with asthma about reducing risk of exacerbations. This is mainly:

1. Don’t smoke – you will increase your risk of an attack significantly and you will need to take more medication.
2. If someone around you is smoking, politely tell them you have asthma and their smoking could make you very ill, and ask them to step outside or away.
3. Try to avoid atmospheres. Make your home and car smoke free.

Nurses have a key role to play in supporting smoking cessation and tobacco-related behavior change in all patients for the benefit of those with asthma. Free, effective training and resources are available to support nurses with this activity, which can be used to support revalidation and professional development.

References:

1. ASH. Fact Sheet – smoking statistics, 2016. ash.org.uk/files/documents/ASH_93.pdf (accessed 6 July 2016).

2. HSCIC. Statistics on obesity, physical activity and diet. Health and Social Care Information Centre, 2015.

3. HSCIC. Statistics on Alcohol. Health and Social Care Information Centre, 2015.

4. Department for Transport. Reported Road Casualties in Great Britain: Main Results, 2014. gov.uk/government/statistics/reported-road-casualties-in-great-britain-main-results-2014 (accessed 6 July 2016).

5. HSCIC. Statistics on Drug Misuse, England – 2014. Health and Social Care Information Centre, 2014.

6. PHE. HIV New Diagnoses, Treatment and Care in the UK. Public Health England, 2015.

7. ASH. Fact Sheet on smoking: Illness and death. ash.org.uk/files/documents/ASH_107.pdf (accessed 6 July 2016).

8. HSCIC. Statistics on Smoking in England. Health and Social Care Information Centre, 2015.

9. Croghan E. Smoking in Schools Survey, 2003, unpublished correspondence.

10. US DHHS. The Health Consequences of Smoking – 50 Years of Progress: A Report of the Surgeon General. Department of Health and Human Services, 2014. 

11. Asthma UK. Smoking and second-hand smoke. asthma.org.uk/advice/triggers/smoking/ (accessed 6 July 2016).

12. Vardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou V, Connolly GN, Behrakis PK. Short-term pulmonary effects of using an electronic cigarette. Chest 2012;141(6):1400-1406.

13. WHO. Study group on tobacco product regulation. Waterpipe tobacco smoking: health effects, research needs and recommended actions for regulators, 2nd edition. WHO, 2015.

14. NICE. Brief intervention and referral (smoking). NICE, 2006.

15. NICE. Pathway on smoking brief advice and referral. pathways.nice.org.uk/pathways/smoking (accessed 6 July 2016).

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