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Stopping smoking: the importance of nicotine addiction
  1. ANGELA HILTON, Consultant Respiratory Physician
  1. & Chairman of the BTS Tobacco Committee
  2. North West Lung Centre
  3. Wythenshawe Hospital
  4. Manchester M23 9LT
  5. UK

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    The Royal College of Physicians has produced several reports on the adverse effects of smoking on health in the past 40 years.1-5 Its latest report entitled “Nicotine Addiction in Britain” emphasises the importance and role of nicotine addiction as a major factor in making many smokers unable to stop.6 Recognition of the addictive nature of nicotine has important implications for the way that nicotine products should be regulated in society, and one important conclusion of the report is that tobacco based nicotine products should be subject to the same regulatory control as any other drug delivery device. However, the report also argues that nicotine addiction should become recognised and accepted as a medical problem, much as any other manifestation of drug addiction, and this argument has special relevance to respiratory physicians.

    Most people who attempt to stop smoking relapse within a very short time and, in the USA, less than 10% of smokers who stop for one day remain non-smokers at 12 months.7 Nicotine replacement therapy has been shown to improve cessation rates in many controlled randomised studies, but these success rates apply mainly to smokers recruited from the general population and general practice.8 However, smokers are a heterogeneous population and those with established smoking related diseases often have even greater difficulty in quitting smoking. Furthermore, amongst patients admitted to hospital, the relative effectiveness of nicotine replacement therapy and of counselling and psychological support may be different, since three multicentre studies of smoking cessation in hospital inpatients and outpatients carried out in the 1980s by the British Thoracic Society showed that simple advice from chest physicians with follow up letters of support and encouragement improved quit rates at one year, and that in this context nicotine replacement therapy did not improve the success rate.9-11 The importance of psychological support and counselling in achieving a quit rate of over 20% at one year, with or without nicotine replacement treatment, has been confirmed by a recent study from Cardiff in hospital patients.12

    Patients with smoking related diseases present to a wide range of hospital specialities. However, respiratory physicians in particular see large numbers of patients with lung cancer and chronic obstructive pulmonary disease (COPD), diseases where smoking is the major aetiological factor, and most of the deaths caused by smoking are in fact due to respiratory diseases.6 Smoking cessation in patients with COPD reduces the accelerated rate of decline of forced expiratory volume in one second (FEV1) and is one of only two interventions which improve the long term prognosis, the other being long term oxygen therapy.13 14 Active support and treatment of nicotine addiction in these patients should therefore be considered to be an essential component for medical management of this disease.

    If nicotine addiction is accepted to be a fundamental issue in preventing smokers from successfully stopping smoking, it is clear that simple advice alone is not always adequate to address the problem. Active help and support such as psychological counselling and pharmacological treatments need to be made available to increase the chances of success. Other addictions such as those to heroin and alcohol are already treated and funded by the NHS, and although funding is now being made available to establish smoking cessation services in selected areas of Britain, it is time to make the treatment of nicotine addiction available and affordable for all smokers through the NHS. Smoking cessation interventions give good value for money and the cost implications of providing smoking cessation services in the UK are well established.15 The report by the Royal College of Physicians adds further urgency to the need for the implementation of smoking cessation services.

    It is also important for all health professionals to take an active role in advising and helping smokers to stop.16 For this to be achieved, there must be better education and training for health professionals in both the knowledge of the adverse effects of active and passive smoking and in smoking cessation methods. Unfortunately, marked deficiencies in knowledge of tobacco control and prevention have been shown amongst medical students from all over the world.17 Few medical schools include education on tobacco issues in their undergraduate curriculum and the prevalence of smoking amongst medical students increased during their medical school careers. Even for specialist registrars training in respiratory medicine, the current curriculum does not include a recommendation for training in smoking cessation as an essential part of the syllabus.18

    What messages can respiratory physicians take from the latest Royal College of Physicians report? Many of our patients need help and support to stop smoking and, because so many of our patients have smoking related diseases, it would be appropriate for respiratory specialists to take ownership of the problem and become lead physicians for tobacco control within their NHS trusts or districts. This would involve a more active role in the education and training of medical students, junior doctors, general practitioners, and other health care professionals in smoking issues especially, and for respiratory physicians to become expert in smoking cessation interventions. Respiratory physicians should actively campaign for and request the appointment of smoking cessation counsellors in all NHS hospitals to provide advice and psychological support for patients and staff. They could work closely with such individuals who could have their base within respiratory medicine departments. The pharmacological aspects of smoking cessation could also become part of the expertise of the respiratory specialist.

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