Initial Clinical Management of Adult Smokers in Secondary Care

Overview

This specialist Guidelines summary provides information and guidance on the initial clinical management of nicotine addiction using nicotine replacement therapy (NRT) in adults who are admitted for short-, medium- or long-term stays in secondary care.

This summary is intended for use by secondary care practitioners.

Refer to the full guideline for the complete set of recommendations.

Introduction

• It is illegal to smoke on hospital grounds across Wales (with the exemption of mental health units). Therefore, it is important that adults who smoke are provided with, or signposted to, pharmacotherapy and/or behavioural support to manage the symptoms of nicotine withdrawal. This applies to people who smoke, in the following categories:
  • inpatient
  • outpatient
  • visitors and staff (please see full guideline for further information)
• This guidance is intended for patients that are admitted and are not already using pharmacotherapy for smoking cessation. All pre-admission medications should be prescribed as part of the patient’s regular medications
• Oral pharmacotherapies should only be initiated following a full smoking cessation assessment, including assessment of nicotine dependency. For more information on how to assess nicotine dependence please refer to the All Wales Guide: Pharmacotherapy for Smoking Cessation February 2018.

Inpatients

• All patients who are admitted to a ward should be asked about their smoking status (current smoker, ex-smoker, non-smoker [history unknown], never smoked, or not stated). Help Me Quit advises, in its minimum service standards, that current smoking status is recorded in at least 90% of patient records. This is the responsibility of all staff.

Initial Assessment

• Ask patients if they smoke; if they do not smoke, no follow up is necessary; if they do smoke, determine the type and amount consumed daily
• Assess their pharmacotherapy needs based on the information provided (see Algorithm 1) and
• Advise them on the health effects and benefits of stopping
• Act: offer and consider prescribing NRT to help the patient cope with nicotine withdrawal. For inpatients, prescribe for the duration of their stay and a minimum of 2 weeks on discharge. Patients who request or are interested in trying an oral agent as part of a quit attempt should be referred to either a secondary care smoking cessation practitioner (SCSCP), doctor, or prescribing pharmacist.

Managing Smoking in Patients

• Patients who smoke and are admitted to hospital will have one of three options:

1. to use their admission as an opportunity to quit smoking using pharmacotherapy and referral for behavioural support for their quit attempt. These patients will receive pharmacotherapy while in hospital and on discharge from hospital
2. to receive NRT to manage withdrawal symptoms while in hospital but to continue to smoke once discharged. These patients will not receive NRT on discharge from hospital
3. not to be provided with NRT while in hospital to manage their nicotine withdrawal symptoms or on discharge. This is a patient’s choice

• Behavioural support will be via the on-site SCSCP while in hospital and continued upon discharge via outpatient appointments with the SCSCP or to a specialist smoking cessation service in the community accessed through the online e-referral to Help Me Quit, depending on what is available locally
• Whether the patient is choosing to start a quit attempt or not, NRT should still be offered to manage the patient’s nicotine withdrawal symptoms while they are in hospital. This is in line with the Help Me Quit minimum service standards, whereby at least 80% of smokers should receive at least one offer of stop smoking support in a given period of engagement
• The fact that patients are unable to smoke while in hospital provides an opportunity for healthcare staff to provide brief interventions to encourage patients to consider stopping or reducing their smoking.

Role and Responsibilities

• Refer to the full guideline for the complete list of roles and responsibilities, including: nursing staff; pharmacy staff; secondary care smoking cessation practitioners; clinical leads; managers and executives.
• Also refer to local Smoke-Free Environment Policies
• On admission to a health board, the smoking status of all patients should be obtained and documented in the relevant section of the patient’s medical notes
• All staff should be encouraged to undertake brief intervention training to support local smoke-free environment policies. Training can be provided by the SCSCPs on a rolling programme, or locally through Help Me Quit. Refer to local guidance
• The smoking status of the patient can be obtained by following the procedure outlined in the section, Initial Assessment (above)

Prescribers

• Reinforce ‘no smoking on site’ message
• Prescribe initial NRT. Guidelines for prescribing NRT are given in Algorithm 1
• Refer patients for behavioural support via an SCSCP, if available, or to Help Me Quit for follow up upon discharge
• If NRT has been initiated then the inpatient medication administration record should be endorsed in the special instructions box with either Quit Attempt, for those patients who are trying to give up smoking long-term, or Withdrawal Management, for those patients who only wish to have NRT support while they are inpatients
• For patients who are smoking more than 10 cigarettes a day, ‘additional when required’ NRT will also be needed (see Algorithm 1) and the patient should have a supply of the ‘when required’ medicine at all times
• Patients who express an interest in using an oral pharmacotherapy that is not nicotine-based: varenicline or bupropion, must be referred to an SCSCP (where available) or via the Help Me Quit professional referral form (online) indicating that access to a service that can prescribe these medications is required
• Ensure smoking cessation medications are added to the patient’s discharge summary.

Nicotine Replacement Therapy Prescribing

Initial Prescribing of NRT

• N.B. This document is intended for patients that are admitted and are not already using pharmacotherapy for smoking cessation. All pre-admission medications should be prescribed as part of the patient’s regular medications
• All patients require a complete assessment and a treatment plan, which should be based on withdrawal symptoms and dependency. However, at the point of admission to hospital this is not always possible and the patient needs medication urgently to prevent withdrawal. Algorithm 1 can be followed but doesn’t replace the need for a complete assessment. This applies whether they are starting a quit attempt or not
• When NRT is to be administered, the inpatient medication administration record must be endorsed with either Quit Attempt or Withdrawal Management.

Algorithm 1: Initial Prescribing of NRT 

Calculating Number of Cigarettes a Day

• Not all patients who smoke will smoke cigarettes; some will smoke cigars, pipes, or rolling tobacco. Before prescribing NRT the equivalent number of cigarettes a day that the patient is smoking must first be established and documented. Table 1 can be used to convert the amount of tobacco product the patient smokes into an equivalent number of cigarettes a day

Table 1: Guide to Work Out Cigarette Equivalents of Tobacco Smoked

• For patients who have reduced the number of cigarettes smoked per day in the days prior to their admission to hospital (due to being unwell), the initial NRT should be calculated using the current number of cigarettes smoked per day. With a note that these patients may require up-titration of their NRT depending on individual patient response, to cover the number of cigarettes they were previously smoking per day
• Patients not showing nicotine dependence may choose not to have NRT; this should always be the patient’s choice.

Additional When Required (PRN) Prescribing of NRT

• For patients who are prescribed regular NRT (either for a quit attempt or for withdrawal management) an assessment should also be made to establish what additional PRN NRT is needed to deal with cravings and withdrawal symptoms. It is well established that patients are more successful when given regular and PRN NRT together. (see Table 2).

Table 2: Guidance for Prescribing Additional When Required NRT

Pre-quit Nicotine Products

• Most NRT products currently available are now also licensed as pre-quit nicotine replacement therapy. The following standard statement is contained within their summaries of product characteristics:
  • ‘Indicated to aid smokers wishing to quit or reduce prior to quitting, to assist smokers who are unwilling or unable to smoke, and as a safer alternative to smoking for smokers and those around them’
• The exceptions to this are the nasal spray and a few of the low-dose oral products. In general, patients requiring the lower dose products do not smoke large numbers of cigarettes per day and so a pre-quit approach is not usually appropriate.

Access to NRT within the Secondary Care Setting

• To ensure timely and consistent treatment with NRT, all settings where people who smoke are seen and assessed should have a basic stock of pharmacotherapy to aid smoking withdrawal symptoms.

Behavioural Support and Advice

• Advice should be provided to all patients prescribed NRT on the signs and symptoms of nicotine withdrawal
• Nicotine withdrawal signs and symptoms include:
  • urges
  • anxiety/depression
  • aggression
  • increase in appetite
  • inability to concentrate
  • sleepiness/sleeplessness
  • mouth ulcers
  • constipation
• The signs and symptoms of nicotine withdrawal can sometimes be viewed as a side effect of NRT products. Therefore, it is important that the patient is counselled on the withdrawal signs and symptoms of nicotine, in order to prevent non-compliance with NRT products
• Patients should be advised that most warnings for NRT also apply to continued smoking but the risk of continued smoking outweighs any risks of using NRT. This advice should be given at the point of prescribing, but can be reiterated by the prescriber, SCSCP, nurse, or the pharmacist responsible for the patient.

Additional Prescriber Support for Complex Patients

• For patients that are smoking more than 20 cigarettes or equivalent a day (or are experiencing difficulties), refer to one of the SCSCPs or a healthcare professional with a specialist interest in smoking cessation.

Discharge Process

• Patients making a quit attempt should receive at least 14 days’ supply of smoking cessation pharmacotherapy or enough to last until the first follow-up appointment with a smoking cessation service. The quit attempt and medication prescribed in hospital should be documented on the patient’s discharge medication report along with any follow-up arrangements. The patient should be advised that smoking cessation services are provided through Help Me Quit (including referral to community pharmacy services) and that contact should be made to these services via Help Me Quit (see the section, Additional Patient Support on Discharge) rather than contacting GP surgeries
• For patients who have not decided to start a quit attempt and have been treated with NRT for nicotine withdrawal only (during their inpatient stay), no supply of NRT shall be provided on discharge.

Additional Patient Support on Discharge

• For patients who are attempting to stop smoking long term and have started their quit attempt during their hospital stay, it is important that supply of medication and behavioural support is available seamlessly upon discharge. This can be either by follow-up outpatient appointments with the SCSCP or by referral to the Help Me Quit service by a healthcare professional
• A booklet, Passport to Smoke Free, can also be provided from ward level prior to discharge. If referring via the Help Me Quit professional referral form, you must indicate if the patient has started a quit attempt during their hospital stay, as not all services can accept someone that has already started a quit attempt.

Outpatients

• When attending outpatient appointments all patients should be asked if they smoke and offered brief intervention advice. Where the appointment is at a pre-admission clinic, information should be provided about the smoke-free status of the hospital in preparation for their admission
• Should they wish to start a quit attempt a referral can then be made to either an SCSCP or a specialist smoking cessation service in primary care (via Help Me Quit)
• When a patient has already been seen as an inpatient by an SCSCP, every effort should be made to combine outpatient follow-up appointments with smoking cessation appointments
• For patients that have been referred to an SCSCP, following the assessment (where appropriate), an initial supply of NRT should be provided by the SCSCP. This is to ensure continuity of supply until a primary care supply is available.

Training

All Staff

• Recommended UK-accredited smoking cessation training is provided by the National Centre for Smoking Cessation and Training (NCSCT). The NCSCT Online Smoking Cessation Training is open for all professional staff including nursing, pharmacy staff, and prescribers. The training includes Very Brief Advice, Brief Intervention, Level Two and Stop Smoking Medication Training for anyone providing stop smoking support, and can be accessed via: elearning.ncsct.co.uk/wales
• Please note the SCSCPs are also available to provide departmental training.

Prescribers

• Smoke Free Environment Policy for their health board
• All Wales Guide: Pharmacotherapy for Smoking Cessation February 2018.

Secondary Care Smoking Cessation Practitioner Training 

• All SCSCPs must be NCSCT-certified. They must all have completed the relevant NCSCT online training modules and be included on the NCSCT practitioner register
• An additional guidance document will be given to all secondary care smoking cessation practitioners for the assessment of cautions, medication and disease interactions with the use of NRT, in people who smoke and have co-morbidities and those under 17 years of age
• Each health board should have a designated clinical lead as a point of escalation for complex smokers where additional clinical advice is required.