COVID-19 and smoking: what nurses need to know to help people quit for good

The pandemic is providing an incentive for smokers to quit – and nurses can help them

The pandemic is providing an incentive for smokers to quit – and nurses can make sure they succeed

  • When the COVID-19 pandemic began, smokers were advised that they could be more vulnerable to the infection. The pandemic has since motivated many smokers to try to quit
  • Attempts to stop smoking can be more successful with professional support and the use of quitting aids. Nurses should take every opportunity to provide encouragement and advice – even if this is a 30-second prompt
  • Nurses need to counter misperceptions about nicotine and guide patients on the use of nicotine replacements, e-cigarettes, vapes and medication to help them stop

Picture shows someone breaking a cigarette in half. During COVID-19 and for other health reasons, now is a good time to quit smoking

Now is a good time to stop smoking Picture: iStock

Smoking harms nearly every organ of the body.

It causes respiratory disease, cardiovascular disease, lung cancer and many other cancers.

Smoking reduces fertility and significantly raises the risk of developing type 2 diabetes, eye disease and dementia.

COVID-19 presents a new threat to people who smoke

It is the leading modifiable risk factor in pregnancy, associated with miscarriage, premature birth, stillbirth, complications during delivery, neonatal complications and sudden infant death syndrome.

There are already more than enough reasons for health and care professionals to support people who smoke to quit.

Now the COVID-19 pandemic has brought yet another reason.

Chief medical officer Chris Whitty and health and social care secretary Matt Hancock highlighted the increased risk for smokers early on in the COVID-19 outbreak.

Public Health England (PHE) has published advice calling on smokers to quit to reduce their risk of serious illness if they contract COVID-19.

What we know about smoking and COVID-19

Smokers are generally at greater risk of respiratory viruses – smoking damages the lungs and airways and weakens the immune system, making it harder to fight infection.

The hand-to-mouth action of smoking provides another potential route for viruses to enter the body.

Smokers are more likely than non-smokers to have pre-existing conditions such as respiratory disease, cardiovascular disease and type 2 diabetes which are associated with poorer outcomes for people with COVID-19.

Analysis of data from 2.4 million UK users of the COVID Symptom Study app has indicated that current smokers were 14% more likely than non-smokers to develop the three ‘classic’ symptoms of the disease – fever, persistent cough and shortness of breath.

And current smokers who tested positive for COVID-19 were more than twice as likely as non-smokers to be hospitalised.

Mixed messages from international research studies

The international evidence on COVID-19 outcomes for smokers has been mixed.

An ongoing rapid evidence review by researchers at the Royal Veterinary College and University College London finds uncertainty regarding the relationship between smoking status and infection, hospitalisation, disease severity and mortality from COVID-19.

According to the latest version of the review, recorded smoking prevalence among people with COVID-19 was generally lower than the national levels. Current smokers were at reduced risk of testing positive for SARS-CoV-2 compared with people who had never smoked.

Former smokers were at increased risk of hospitalisation, higher disease severity and mortality.

Data on COVID-19 outcomes for current smokers were inconclusive but favoured there being no important associations with hospitalisation and mortality and a small but important increase in the risk of severe disease.

The authors explain that interpretation of results from the reviewed studies is complicated by several factors, including likelihood of being tested and whether smoking status had been recorded.

Could nicotine have a possible ‘protective effect’ on infection?

These mixed research findings have led to speculation regarding a possible ‘protective effect’ of smoking against coronavirus.

‘Should a protective effect from nicotine be found, it is unlikely that this would outweigh the harmful impacts of smoking. Rather, it would provide another reason for smokers to use less harmful sources of nicotine to support them to quit’

There is a biologically plausible explanation for such an effect – that nicotine could be blocking the same receptors used by the virus to get into the body’s cells.

A clinical trial is underway in France to see whether nicotine patches can help prevent or lessen symptoms of COVID-19.

Smoked tobacco is by some way the ‘dirtiest’ form of nicotine delivery and should a protective effect from nicotine be found it is unlikely that this would outweigh the harmful impacts of smoking.

Rather, it would provide another reason for smokers to use less harmful sources of nicotine to support them to quit, already recommended as evidence-based treatment.

What is clear is that stopping smoking brings rapid improvements in respiratory and cardiovascular health, benefiting individuals and reducing the risk of acute events that require hospital admission at a time of intense pressure on the NHS.

There is evidence that many smokers are fearful of their risks from COVID-19 and the motivation to quit is high.

The University College London Smoking Toolkit Study has found that about one in seven smokers in England who made a quit attempt last year were successful, while this year the success rate has risen above one in five.

‘About half of all smokers in England try to quit unaided using willpower alone, despite this being the least effective method’

So, while in 2019 fewer than one in 20 smokers reported having quit in the previous year – this year the rate is closer to one in 12.

This is a teachable moment and the pandemic has provided an opportunity that nurses should seize.

The importance of support in quitting smoking

Smoking is not a lifestyle choice but a dependency and many smokers need help to quit.

Supporting a smoker to quit is one of the most effective ways any health and care professional can help improve a smoker’s health.

Smokers often make many attempts to quit before managing to stop for good. Currently, about half of all smokers in England try to quit unaided using willpower alone, despite this being the least effective method.

‘Supporting a smoker to quit is one of the most effective ways any health and care professional can help improve a smoker’s health’

Prompts by health and care professionals are one of the most important triggers for an attempt to quit and the success of these attempts can be significantly increased by helping patients identify appropriate quitting aids and access further support:

  • Using over-the-counter nicotine replacement therapy (NRT) products or e-cigarettes makes it one and a half times as likely a person will succeed.
  • A person’s chances of quitting are doubled if using stop smoking medication prescribed by a GP, pharmacist or other health professional.
  • Combining stop smoking aids with expert support from local stop smoking services makes someone three times as likely to quit.

More information on quitting options and their effectiveness can be found in Health Matters: Stopping Smoking – What Works? and Stop Smoking Options: Guidance for Conversations With Patients.

The National Centre for Smoking Cessation and Training (NCSCT) provides a free online training module on stop smoking medications.

Half a minute for nurses to help save a life

National Institute for Health and Care Excellence (NICE) guidance acknowledges that some healthcare professionals worry that people who smoke may feel they are being given too much advice.

However, it is clear that missing the chance to give appropriate advice carries a greater risk of harm.

Talking to people about smoking in a way that is sensitive to their preferences and needs will ensure they are more likely to think about stopping when prompted.

All nurses should be offering the ‘Very Brief Advice’ model (VBA) from the National Centre for Smoking Cessation and Training as part of routine care, and they should know about locally available specialist support and how to refer smokers.

VBA is recommended by NICE and consists of three steps:

  • ASK and record smoking status – is the patient a smoker, ex-smoker or non-smoker?
  • ADVISE on the best way of quitting – the best way of stopping smoking is with a combination of stop smoking aids and specialist support
  • ACT on patient response – build confidence, give information, refer and prescribe

It takes as little as 30 seconds and has the power to transform the future life chances of someone who smokes.

During the COVID-19 pandemic, this is more important than ever.

How to counter harmful misperceptions about nicotine

While nicotine is the addictive substance in cigarettes, it is relatively harmless.

In fact, almost all of the harm from smoking comes from the thousands of other chemicals in tobacco smoke, many of which are toxic.

Despite this, research by King’s College London finds that among smokers and former smokers in the UK, only six in ten think that NRT is less harmful than smoking cigarettes.

Four in ten incorrectly think nicotine in cigarettes causes most smoking-related cancer.

Given these misperceptions, advising smokers on the relative safety of nicotine containing products compared with smoked tobacco is an integral part of supporting them to quit.

People should be advised to use NRT, or an e-cigarette if they prefer, to help them manage their cravings when they stop smoking.

How to advise patients about e-cigarettes and vapes

E-cigarettes, also known as vapes, are the most popular stop-smoking aid in England, with 2.5 million users in 2019.

More than half of current vapers have managed to stop smoking completely and it is estimated that e-cigarettes may help more than 50,000 smokers a year in England to quit who would not have done so by other means.

E-cigarettes are particularly effective when combined with a structured programme of behavioural support.

Although e-cigarettes aren’t currently available as licensed medicines in the UK, they are tightly regulated for quality and safety.

Manufacturers must notify the Medicines and Healthcare products Regulatory Agency of all products with detailed information including the listing of all ingredients.

Safety and effectiveness of e-cigarettes and vapes

The toxic substances contained in cigarette smoke are either completely absent in e-cigarette vapour, or present at much lower levels.

Leading health organisations including the Royal College of General Practitioners, Royal College of Physicians, RCN, PHE, British Medical Association and Cancer Research UK agree that although not risk-free, e-cigarettes are far less harmful than smoking.

The evidence on e-cigarette safety is presented in this short film from the National Centre for Smoking Cessation and Training.

Growing evidence shows e-cigarettes can help smokers to stop smoking.

A major UK clinical trial found that, when combined with expert face-to-face support, people who used e-cigarettes to quit were twice as likely to succeed as people who used other nicotine replacement products such as patches or gum.

E-cigarettes are the subject of frequent and often inaccurate media reporting and it is therefore likely that smokers considering them as an aid to quit smoking will have questions.

National Institute for Health and Care Excellence guidance recommends healthcare professionals provide advice to smokers who are using, or who are interested in using, an e-cigarette for quitting, including that:

  • Many people have found e-cigarettes helpful to quit smoking cigarettes
  • Evidence suggests they are substantially less harmful to health than smoking but are not risk-free
  • People using them should stop smoking completely because any smoking is harmful.

Little research has been conducted into the safety of e-cigarettes in pregnancy, however they are likely to be significantly less harmful to a pregnant woman and her baby than smoking cigarettes.

The Smoking in Pregnancy Challenge Group – a coalition of royal colleges, the voluntary sector and academia – advises that while licensed NRT products are the recommended option, if a pregnant woman chooses to use an e-cigarette and if that helps her to quit smoking and stay smoke-free, she should be supported to do so.

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Public Health England tobacco control lead Martin DockrellPublic Health England deputy chief nurse Jamie WaterallMartin Dockrell (left) is tobacco control lead at Public Health England; and Jamie Waterall is deputy chief nurse at Public Health England