Health Care Professional

Information Note on Smoking Cessation

Smoking Cessation is Life-saving

Smoking is the leading preventable cause of mortality and morbidity in our population. Lung cancer caused the highest mortalities among all cancers1. Heart and cerebrovascular diseases ranked the third and the fourth in the number of deaths from all causes in 2020, respectively2. At least half of all smokers were killed by their cigarettes3. Being a major risk factor for cancers and various systemic diseases4, smoking is also a significant risk factor for dental complications5, 6. There is conclusive evidence showing that smoking causes diseases in nearly every organ and system of the body4.

Example of Organs and Systems Affected by Smoking4
Heart
Coronary heart disease		 Vascular
Peripheral vascular disease, aortic aneurysm
Eye
Cataracts, age-related macular degeneration		 Brain
Stroke
Head and neck
Periodontitis, cancer of oropharynx, cancer of larynx		 Lung
Lung cancer, COPD, tuberculosis, asthma
Alimentary tract
Cancer of esophagus, stomach, liver, pancreas, colon and rectum		 Reproductive
Erectile dysfunction in men, ectopic pregnancy and reduced fertility in women, and orofacial clefts
Urinary
Cancer of kidney, ureter and bladder 		Blood
Acute myeloid leukaemia
Endocrine
Diabetes		 Autoimmune
Rheumatoid arthritis

In spite of the substantial risks, more than 60% of daily smokers in Hong Kong have neither attempted nor wanted to quit. In 2019, less than 5% of current smokers have ever used smoking cessation services7.

Smokers are More Vulnerable to COVID-19

Smoking is associated with increased risk of progression to severe diseases (i.e. requiring mechanical ventilation or intensive care) and deaths among hospitalized COVID-19 patients8, 9. Patients with COPD and cardiovascular diseases, which are strongly associated with smoking, are also at higher risk of severe COVID-1910, 11.

Cessation is Beneficial at All Ages

Quitting is beneficial to smokers of all ages and brings immediate and long-term health benefits12. It significantly reduces risk of smoking related illnesses, and prevents disease progression and mortality in persons with chronic illness.

Immediate and Long Term Benefits of Quitting
  • Within 12 hours
    - Carbon monoxide level in blood drops to normal13
  • Within 2 to 12 weeks
    - Circulation and lung function improves13
  • After 1 to 9 months
    - Coughing and shortness of breath decrease13
  • After 1 to 5 years
    - The risk of coronary heart disease is reduced by 50%14
    - The risk of stroke is reduced to the level of never smokers15
  • After 5 to 10 years
    - The risk of lung cancer is reduced by 50%, and will be further reduced with continued cessation15
    - The risk of acute myeloid leukaemia, cancer in stomach, pancreas, cervix, colon/rectum, liver, and kidney is reduced by various degree14
    - The risk of developing diabetes is reduced to that of never smokers16
  • After 10-15 years
    - The risk of coronary heart disease is that of a non-smokers13
  • Other benefits of quitting
    - Smoking cessation is the only proven strategy to reduce the risk of developing COPD and the only intervention that reduce lung function decline in people with COPD14
    - The risk of recurrent infarction and premature death is reduced by more than 50% among persons diagnosed with coronary heart disease15

Evidence-based Cessation Interventions

Effective cessation methods include self-help, web-based intervention, brief advice by health professionals, behavioral support, and pharmacotherapy. Each intervention is effective independently, and quit rate increases when they are used in combination and with increasing intensity of intervention17. The most effective way to quit is the combination of pharmacotherapy with behavioural support17, 18.

Although the majority of smokers attempted to quit did so without assistance, studies found the 6-month abstinence rates of unassisted quitting to be low, ranging from 3% to 5%19. Studies showed that healthcare professionals offering advice as brief as three minutes or less17, or a very brief advice (“VBA”) lasting for 1 minute or less can improve abstinence. 20，21,22Brief advice provided by physicians increases quit rate by 66%23. Pharmacotherapy increases quit rate by 50% to 200%17. Currently two types of pharmacotherapy are available in Hong Kong: nicotine replacement therapy (“NRT”, including patch, gum and lozenge) and varenicline. Using NRT alone can nearly double the odds of quitting, while using varenicline or combination-NRT can triple the odds24.

Role of Healthcare Professionals

To achieve the greatest impact at the population level, delivering brief advice to most smokers may prove more effective and efficient than spending a long time with a few25. The World Health Organization advocates brief advice to be delivered by all health professionals using 5A’s and 5R’s models, which typically take 3 to 5 minutes26.

Very Brief Advice

Healthcare professionals can ask about smoking status, give advice on quit smoking and actively refer to smoking cessation service in less than 30 seconds by delivering “Very brief advice” (VBA). “VBA” is an established and widely practiced cessation intervention model 17,27,28,29,30. VBA is effective in triggering quit attempts and increasing smokers’ access to cessation support31, and it should be delivered to all smoking patients at every opportunity. VBA can last as short as 30 seconds and comprises only three steps:

Three Steps of Very Brief Advice
    1. Ask whether the patient smokes or has ever smoked
    2. Advise all smokers that combining counselling and pharmacotherapy yields the best result for quitting
    3. Offer referral to cessation services, irrespective of smoker’s desire to quit, and provide information pamphlet. Smokers declining referral are encouraged to make use of the pamphlet and seek assistance any time.

Delivery of VBA does not require detailed knowledge in smoking cessation. It is effective when delivered by a wide range of health professionals including doctors, dentists, nurses, pharmacists, dental hygienists, physiotherapists and other allied health professionals17.

It is of utmost importance to revisit the issue of smoking in future visits, as nicotine dependence is a chronic relapsing condition requiring ongoing care32. VBA should be delivered again to smokers who have not yet quitted. Those who have quitted should be encouraged to remain abstinent.

Brief Intervention

Healthcare professionals can deliver brief intervention on smoking cessation in 3 to 5 minutes. They may deliver counselling together with pharmacotherapy like nicotine replacement therapy (“NRT”, including patch, gum and lozenge) or varenicline, to assist patient in smoking cessation.

The 5A’s model (Ask, Advise, Assess, Assist, and Arrange) can be applied to smokers who are ready to quit27:

The 5A’s model
Step Content
Ask
  • Ask ALL patients at each consultation about the smoking status, daily consumption and years of smoking, and record the information accordingly
  • Include smoking status of the patient as one of the vital signs and record such information prominently
Advise
  • • Convince the patient to quit smoking with a clear, personalised and strong manner, e.g. “Quitting smoking is the most important thing you can do to protect your health”, “Quitting smoking can delay the progression of COPD”
Assess
  • Assess each patient’s desire and readiness to quit
    1. Would you like to quit smoking?
    2. Do you think you have a chance of quitting successfully?
  • If answer to either question is yes, can move on to the next step “Assist”
  • If answer to both question is no, or if patient is unsure if they want to quit smoking, can deliver 5R’s intervention
Advise
  • Work out with the patient on the smoking cessation plan, e.g. set a quit day and encourage the patient to tell family members, colleagues and friends to enlist their support and encouragement.
  • Provide appropriate techniques on problem solving and give advice for successful quitting
  • Recommend the use of pharmacotherapy for smoking cessation and assist in making referral
  • Provide relevant smoking cessation information such as pamphlets or quitline card
安排跟進（Arrange）
  • Work out with the patient on follow-up schedule and approaches such as interviews and telephone calls
  • Recognise the efforts of those who have successfully remained tobacco-free, and remind those who are still unable to kick the habit to regard occasional “slips” as an alert
  • If a relapse occurs, encourage the client to repeat quit attempt and review cause of relapse

Tobacco users may be unwilling to quit due to misconception or demoralization because of previous unsuccessful quit attempts. The 5R’s intervention (Relevance, Risk, Rewards, Roadblocks, and Repetition) can be delivered to those who are not ready to quit tobacco use after the “Assess” stage of the 5A’s27.

The 5R’s model
Step Content
Relevance
  • Get the patient to understand why his/ her quitting is relevant to him/ her personally and to the people around
Risk
  • Guide the patient to identify potential negative consequences of tobacco use that are relevant to him/ her
Rewards
  • Get the patient to understand the personally relevant benefits brought about by smoking cessation
Roadblocks
  • Guide the patient to assess various barriers to quitting, e.g. experience of withdrawal symptoms or fear of repeated failure, and provide counselling accordingly
Repetition
  • Make good use of every contact opportunity by repeating motivational intervention

Local Cessation Services

The Department of Health operates the Quitline (1833 183) to provide cessation counselling, information and referral to various free cessation services. The clinics providing cessation services are highly accessible with opening hours that include evenings and weekends, and serve multiple locations with fixed and mobile clinics.

Smoking Cessation Services
Services Features
Telephone counselling -
DH Quitline 1833 183
  • Provide counselling, information and referral to various free cessation services
Behavioural intervention coupled with medication
  • Fixed and mobile clinics 
  • Also provide services for people of diverse race and new immigrants 
  • Free postal delivery of nicotine replacement therapy if necessary
Behavioural intervention coupled with acupuncture cessation service
  • Fixed and mobile clinics
Telephone counselling -
Youth Quitline
  • For smokers aged 25 or below 
    Service provided by peer counsellors

Resources for Health Professionals

To help healthcare professionals deliver VBA or brief intervention, an online training course and other relevant materials, including a VBA delivery flowchart, a brief intervention with 5A’s/5R’s model delivery flowchart, a patient pamphlet, a referral guide, as well as a comprehensive Practical Handbook for Smoking Cessation Treatments can be downloaded from http://www.livetobaccofree.hk or obtained from the Department of Health.

Reference

  1. Hospital Authority. Hong Kong Cancer Registry. https://www3.ha.org.hk/cancereg/ (accessed 7 January 2022).
  2. Centre for Health Protection, Department of Health. Number of Deaths by Leading Causes of Death, 2001 – 2020. https://www.chp.gov.hk/en/statistics/data/10/27/380.html (accessed 7 January 2022).
  3. World Health Organization. Tobacco Key Facts. https://www.who.int/news-room/fact-sheets/detail/tobacco (accessed 11 January 2022).
  4. U.S. Department of Health and Human Services. The health consequences of smoking - 50 years of progress: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2014.
  5. Leite FRM, Nascimento GG, Scheutz F, López R. Effect of Smoking on Periodontitis: A Systematic Review and Meta-regression. Am J Prev Med. 2018;54(6):831-841. doi:10.1016/j.amepre.2018.02.014.
  6. Alfadda SA. Current Evidence on Dental Implants Outcomes in Smokers and Nonsmokers: A Systematic Review and Meta-Analysis. J Oral Implantol. 2018;44(5):390-399. doi:10.1563/aaid-joi-D-17-00313.
  7. Census and Statistics Department, HKSAR Government. Thematic Household Survey Report No. 70. Hong Kong: Census & Statistics Department, 2020.
  8. World Health Organization. Smoking and COVID-19 Scientific Brief. https://www.who.int/news-room/commentaries/detail/smoking-and-covid-19 (accessed 11 January 2022).
  9. WHO supports people quitting tobacco to reduce their risk of severe COVID-19. https://www.who.int/news/item/28-05-2021-who-supports-people-quitting-tobacco-to-reduce-their-risk-of-severe-covid-19 (accessed 11 January 2022)
  10. Alqahtani JS, Oyelade T, Aldhahir AM, et al. Prevalence, Severity and Mortality associated with COPD and Smoking in patients with COVID-19: A Rapid Systematic Review and Meta-Analysis. PLoS One. 2020;15(5):e0233147. doi:10.1371/journal.pone.0233147.
  11. Yancy CW, Fonarow GC. Coronavirus Disease 2019 (COVID-19) and the Heart-Is Heart Failure the Next Chapter? [published online ahead of print, 2020 Jul 27]. JAMA Cardiol. 2020;10.1001/jamacardio.2020.3575. doi:10.1001/jamacardio.2020.3575.
  12. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004;328(7455):1519. doi:10.1136/bmj.38142.554479.AE.
  13. World Health Organization. Health benefits of smoking cessation. https://www.who.int/news-room/q-a-detail/health-benefits-of-smoking-cessation (accessed 11 January 2022).
  14. U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. Smoking Cessation: A Report of the Surgeon General. Rockville, MD, US2020.
  15. U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Rockville, MD, US1990.
  16. Will JC, Galuska DA, Ford ES, Mokdad A, Calle EE. Cigarette smoking and diabetes mellitus: evidence of a positive association from a large prospective cohort study. Int J Epidemiol. 2001;30(3):540-546. doi:10.1093/ije/30.3.540.
  17. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.
  18. Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016;3:CD008286. doi:10.1002/14651858.CD008286.pub3.
  19. Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction. 2004; 99(1):29-38. doi: 10.1111/j.1360-0443.2004.00540.x.
  20. Wu L, He Y, Jiang B, et al. Very brief physician advice and supplemental proactive telephone calls topromote smoking reduction and cessation in Chinese male smokers with no intention to quit: a randomized trial. Addiction. 2017;112(11):2032-2040
  21. Lin PR, Zhao ZW, Cheng KK, Lam TH. The effect of physician's 30 s smoking cessation intervention for male medical outpatients: a pilot randomized controlled trial. J Public Health (Oxf). 2013;35(3):375- 383.
  22. Cheung YTD, Jiang N, Jiang CQ, et al. Physicians’ very brief (30-sec) intervention for smoking cessation on 13 671 smokers in China: a pragmatic randomized controlled trial. Addiction. 2020 Sep 12. doi: 10.1111/add.15262
  23. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann‐Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD000165. DOI: 10.1002/14651858.CD000165.pub4.
  24. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013;(5):CD009329. doi:10.1002/14651858.CD009329.pub2.
  25. The Royal Australian College of General Practitioners. Supporting smoking cessation: A guide for health professionals. https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/supporting-smoking-cessation (accessed 11 January 2022).
  26. WHO. Toolkit for delivering the 5A’s and 5R’s brief tobacco intervention in primary care. Geneva, Switzerland: World Health Organization, 2014.
  27. National Centre for Smoking Cessation Training. Very Brief Advice on Smoking. https://elearning.ncsct.co.uk/vba-stage_1 (accessed 11 January 2022).
  28. Royal College of Physicians. Hiding in plain sight: treating tobacco dependency in the NHS. London: RCP, 2018.
  29. Centre for Addiction and Mental Health. Canadian Smoking Cessation Clinical Practice Guideline. OntarioAvailable at https://www.nicotinedependenceclinic.com/en/canadaptt/PublishingImages/Pages/CAN-ADAPTT-Guidelines/CAN-ADAPTT%20Canadian%20Smoking%20Cessation%20Guideline_website.pdf (accessed 11 January 2022).
  30. Ministry of Health (NZ). The New Zealand guidelines for helping people to stop smoking. Wellington: Ministry of Health, 2014. https://www.health.govt.nz/publication/new-zealand-guidelines-helping-people-stop-smoking (accessed 11 January 2022).
  31. McEwen A et al. Adapting Very Brief Advice (VBA) on smoking for use in low-resource settings: Experience from the FRESH AIR project. Journal of Smoking Cessation, 14(3), 190-194. doi:10.1017/jsc.2019.4
  32. Borland R, Partos TR, Yong HH, Cummings KM, Hyland A. How much unsuccessful quitting activity is going on among adult smokers? Data from the International Tobacco Control Four Country cohort survey. Addiction. 2012;107(3):673-682. doi:10.1111/j.1360-0443.2011.03685.x.
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