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Smoke-Free Challenges & ‘Butts’: strategies
to engage patients, carers & staff
Dr Peter Mackereth (Former) Tobacco Control Lead
Charlotte Finchett Lead Health Advisor
The Christie NHS Foundation Trust
Manchester
Agenda:
To examine how we can
engage patients, carers
and staff in smoking
cessation services,
exploring the ‘butts' and
benefits of going smoke
free based on case
studies, interventions and
strategies to help
individuals make the
change
Smoking, Cancer & Treatment
Contains 4,000 chemicals including:- arsenic,
formaldehyde, butane, acetone, methanol
NOW 30% sugar!! – increased sweetness & burn attracts
young people & women
Carbon monoxide (poisonous invisible gas) – prevents
oxygen transport & detrimental effects on healing (XRT &
surgery)
Contraindicated with chemotherapy – effects on uptake &
circulation
Increases risk of nausea & vomiting with chemotherapy
Higher rates of recurrence & new lung primaries
Smoking & Drug Interactions e.g.
Heparin – increased clearance & decreased half life
Beta- blockers - less effective antihypertensive & rate control effects
Insulin – decreased insulin absorption, antagonizes the effects of insulin, higher insulin dose needed
Opioids - smoking decreases analgesic effects so higher doses needed
Chemotherapy – higher doses required – more mutations so harder to treat
Antidepressants & anxiolytics – higher dosages required in people who smoke
Smoking as a dirty deadly delivery system
Sexing up the use of NRT
E-cigarettes – 3 million users switching – some evidence of dual use & dialling down nicotine level
Don’t forget - snuff, shisha, paan/ betel leaf & cannabis
Smoke Free Site – no shelters
Compliance with NICE guidance
CQC inspection highlighted work of the Christie Health advisors
Ecological impact of smoking – detritus & release of toxins from butts
Teachable moment! – But I am
telling you… I want to carry on smoking. It’s the only
thing that gives me pleasure… I’ve nothing
to look forward to now I have cancer
Don’t ask me to stop right now… I am here
for investigations… not going to get
through today without a cig
I have COPD and lung cancer and I’m in
and out of hospital …smoking makes my
life bearable
I’m here with my mum every day… it gets
me out of the ward and breaks the
boredom of hanging about
Staff …
Student nurse seen by
manager setting with a
patient in a wheelchair
smoking.
Student later explained that
she is sent out at least three
times a day with the patient –
she does not smoke. This
she says this happens to
students at other hospitals
too
Patient seen speaking very
loudly to a nurse smoking in
uniform outside the hospital
….I am shocked… I have
cancer and I was told to stop
and here you are smoking… I
am disgusted
Health Advisor bleeped by
OPD manager to talk to the
nurse
Challenges & ‘Buts’ from Staff
Ignoring the issue - collude with the tobacco industry – but ‘it’s a choice’...it’s lifestyle
But not my role
HCPs that smoke
Being seen as judgmental
Need to value BIT & SEEDING change
Going Smoke free – can be a bumpy journey
Arguments for hospital based Health Advisors
Nurses & Smoking
1- 52 % across the world
Highest – Serbia male
(52%) female (47%)
Lowest – China female
(2%)
45% of nurses who
smoke wanted to stop
11% of Australian nurses
smoke (acute care)
8% of workforce @ the
Christie smoke
Reasons/triggers
/issues
Addiction
Work pressures/ time out
Cope with anxiety
Weight gain concerns
Family/friends smoke
Relationships –
separated/divorce/
loneliness
Shame/ awareness of the
smell
CQUINS Pre-Op, Lung & H&N (4,000)
plus staff training (1,000)
Targeted H&N, lung, breast cancer,
pre-operative Clinics & Wards
Head & Neck Project – reducing
mucositis, insertion of PEGs & hospital
admissions (Stringer et al, 2015).
Survivorship – Podcasts & Health
Events
Smoke Free Site & Services Staff
Survey (Mackereth et al, 2015)
LGBT ‘Proud2BSmokefree’ work
Smoking & Vaping (Heyworth et al,
2017)
The Christie Smoking Cessation Activities
Smoke Free Sites NICE recommendations –
opportunistic rapid access to SC support (NRT) for patients, carers & staff
Singing from same hymn sheet - heard it from doctors, nurses …and pharmacists
‘Walk of shame’ – drip stand by the side of the road.
Risks – increase anxiety & phobias, fire, falls, poor wound healing, delays in discharge etc etc
The Christie NRT Products & Services
Patches □7mg/24 hrs □ 14 mg/24hrs
□ 21mg/24hrs
Lozenge □ 1mg □ 2mg
Inhalator □ 15mg cartridges
Team: Clinical Lead/FT Health Advisor plus 3
PT Advisor/therapists
Interventions: NRT advise/support,
hypnotherapy, stress management techniques
& complementary therapies .
Reframing NRT…sexing it up?
Use NRT to “manage” smoking
Change your brand … provide a choice
Using NRT products innovatively
as…fun… special… black inhalator to
match dress
Getting celebs on board to promote NRT
as life style choice …got my
condoms…got my NRT …on my way
Vaping/e-cigs They are designed to look & feel like normal cigarettes.
Heating element inside that vapourises a solution - this looks like smoke. Glycol plus traces of lead, tin cadmium, flavourings – maybe carcinogenic/irritant
May contain nicotine in varying doses.
Growing in popularity 3 million+ in UK
Recent research paper from The Lancet showed that the e-cigarettes were as effective as nicotine patches.
Further studies are needed to ensure they are safe to use over a length of time.
95 % safer – increasingly viewed as ‘harm reduction’
Growing numbers fires reported in UK– charger burnout, lighting e-cig plus oxygen. Reports of fatalities amongst children with e-liquids plus numerous cases of nausea and sickness
Calls for greater regulation
Concerns about big tobacco taking over the vaping industry
Smoking Cessation Outcomes Jan 14 – July 15
Referrals Patient Carers Staff Total
Reduced 557 6 14 577
Stopped 579 21 40 640
Re-started 12 0 0 12
Unchanged 74 2 6 82
Refused 1 0 0 1
Brief Interventions 3413 356 139 3908
TOTAL 4636 385 199 5220
Dan, aged 56yrs Head & Neck Cancer plus
Dementia (alcohol related) ‘Rollies’ 20+ per
day Completed alcohol detox
Daily radiotherapy / support with mask
Mucousitis, chest infection & loosing weight
Does use NRT inhalator when supervised
NRT Patches on his back
Successfully completed treatment
PEG cancelled as he was better able to eat & drink
Jan, 55, Breast Cancer Bought 100 cigs per day in S. Africa – down to 40 in UK ‘because of
cost’
On chemotherapy & radiotherapy planned
Advised to stop smoking to prevent recurrence/ new lung primary
Memory loss, peripheral neuropathy, breathlessness & very chesty
NRT inhalator, breathing techniques, hypnotherapy (3 sessions) & 6 short sessions for follow up.
Reduced to 20 by end of week 1 - smoke free by 6 weeks.
Disclosed rape in S. Africa – which she believed had triggered escalation in smoking. Attended counselling post treatment
Symptoms improved – able to walk without breathlessness
Recent Christie Study
(Pankhania et al, 2016)
Participants: Patients with lung cancer
(n=140) and family/friends (n=98)
Patients: 103 ex-smokers 31 current
smokers 5 smoked hookah 12 smoked
cannabis. 45 patients used an e-cig 12
dual use. 16 switching to e-cigs and/or
NRT inhalators.
Family/Friends: 38 ex-smokers. 17 current
smokers. 13 had stopped/reduced since
patient was diagnosed. 11 did not feel any
differently about continuing to smoke since
the patient’s diagnosis.
73% of smokers were given information about
the risks of smoking at GPs, 43% in
secondary care and 36% at specialist oncology
clinic.
46% of smokers were given advice about
cessation at GPs,12% in secondary care and
19% in oncology clinic.
87% of patients & 68% of family/ friends felt
differently about smoking since the diagnosis.
Role for HCPs
Always assess smoking status - patients expect to be
asked
Ask about e-cig /vaping usage – safety/comfort issues
Appreciate role of NRT to “manage” smoking during
hospitalization – a step towards becoming smoke free
Provide choices – patches, inhalators combinations
Seed for change …and repeat
Support colleagues to go smoke free
Stack up the positives/gains - improved response to
medication, tissue recovery etc.
Understand role of health advisors/ referral process
Next Steps Research with patients (and carers)
about their experience of NRT,
vaping & smoking cessation
Disseminate Proud2BSmoke Free
LGBT Report
Business case for continuing
Smoking Cessation services
Need for access to NRT for carers
and staff on hospital sites
Partnerships/Integration of hospital
smoking cessation services with
wider GM services
Beyond patients – seed change with
carers & staff – contribute to
reduction GM rates to 13% by 2021.
Our References
Heyworth, B. Roberts, L. Mackereth, P (2017) Proud2BSmokefree. LGBT Cancer Support
Alliance Manchester.
Mackereth, P. Fichett, C, Holt, M (2016) Smoke-free hospital site conversations: how nurses
can initiate change. British Journal of Nursing. 25(21) 1176-1180.
Pankhania, D. Coote, J. Burt, P. Mackereth, P.Finchett, C. Orrett, L. Hodgson, C. Bayman,
N. Blackhall, F. Califano, R. Chan, C. Faivre-Finn, C. Harris, M. Lee, L. Pemberton, L.
Sheikh H. Summers, Y. Taylor, P. (2016) Smoking habits in lung cancer patients and their
carers and audit of advice given. 14th Annual British Thoracic Oncology Group. Conference
Dublin.
Mackereth, P. (2015) Plain packs and more: towards a smoke-free future. British Journal of
Nursing. 24(5):134.
Mackereth, P. Maycock, P. Orrett, L. (2015) Smoke Free Site and service awareness
amongst hospital staff: a survey in an acute cancer centre. Journal of Hospital
Administration. 4(2): 43-47.
Stringer J Mackereth P Knowles R Finchett C Mannan J Slevin N (2015) Health advisor
facilitated mouth care regime for patients with head and neck cancers undergoing intensity
modulated radiotherapy. Journal of Radiotherapy in Practice. 14:353-361.
Mackereth P (2014) Focus on smoking cessation: Calm the craving in cancer care. Practice
Management. Sept Issue, 12-13.
Tomlinson L Mackereth P (2014) Smoking cessation dialogue and the complementary
therapist: Reluctance to engage? Complementary Therapies in Clinical Practice. 20: 181-
187.
Additional References
Bottorff J Robinson C Sullivan K Smith M (2009). Lung cancer patient approaches to
continued family smoking. Oncology Nursing Forum, 36, 126-132.
Cataldo J Dubey S Prochaska J (2010). Smoking cessation: An integral part of lung
cancer treatment. Oncology, 78, 289-301.
Kaufman E Jacobson J Hershman D et al (2008) Effect of Breast Cancer Radiotherapy
and Cigarette Smoking on Risk of Second Primary Lung Cancer. Journal of Clinical
Oncology, 26(3), 392-399.
Lorigan P Radford J Howell A Thatcher N (2005). Lung cancer after treatment for
Hodgkin's lymphoma: a systematic review. Lancet Oncol, 6(10), 773-9.
Lorigan P Califano R Faivre-Finn C Howell A Thatcher N (2010) Lung cancer after
treatment for breast cancer Lancet. 11: 1184-92.
Parsons A Daley A Begh R Aveyard P (2010) Influence of smoking cessation after
diagnosis of early stage lung cancer on prognosis: systematic review of observational
studies with meta-analysis. BMJ. 340: b5569.
Robinson C Bottorff J Smith M Sullivan K (2010). Just because you’ve got lung cancer
doesn’t mean I will: Lung cancer, smoking and family dynamics. Journal of family Nursing
16: 282-301
Travis L Rabkin C Brown L et al. (2006) Cancer survivorship-genetic susceptibility and
second primary cancers: Research strategies and recommendations. Journal of the
National Cancer Institute 98(1):15–25