A Brief Essay On Smoking Policies Within The UK
Tobacco was brought to Europe by Christopher Columbus from America and allegedly introduced to Britain by sir Walter Raleigh who thought it could cure coughs (Marks et al 2006). It became extremely popular in the 20th century, starting from the World War I. During the 1940s and 1950s 80% of men smoked (Marks et al 2006) and some doctors recommended smoking as a method of relaxation (Brannon and Feist 2004). It was only in 1960s when the scientific evidence on the lethal effect of smoking became recognised. This assignment presents the latest knowledge about the impact of tobacco on health and describes governmental and healthcare actions to reduce smoking prevalence, as well as services available for smokers who want to quit.
Tobacco is the second major cause of mortality described by the World Health Organisation (2009) as a 'global epidemic'. Smoking releases about 1500 toxic substances, which damage the organs of active and passive smokers (Marks et al 2006). Second-hand smoke is particularly dangerous in the baby's prenatal stage as it leads to development of fewer but larger alveoli in lungs reducing surface area for gas exchange (Tager 2008). Carbon monoxide in smoke binds with haemoglobin more easily than oxygen causing further oxygen depletion (Stanton et al 2005), while nicotine blocks the development of beta receptors in the heart which protect from hypoxia (Blood-Siegfried et al 2010). The low heart rate of developing baby may lead to miscarriage or postnatal sudden infant death syndrome (Todd 2003). Lack of oxygen and impaired blood flow contributes to malnutrition, therefore babies of smokers are born with smaller body and low birth weight (Weitzman et al 2002). Nicotine also decreases total number of brain cells which may cause future cognitive impairment, poor impulse control and psychiatric disorders (Dwyer et al 2009).
More than 17,000 children in the UK are admitted to hospital every year as a result of passive smoking (Allender et al 2009). Children breathe quicker and have smaller airways (Robinson and Kirckardy 2007) so they are more likely to develop coughs, respiratory diseases and asthma symptoms (Henderson 2007 ). They may also be malnourished as smoking parents tend to spend money on their addiction rather than on food (Marks et al 2006).
Adolescents who smoke have slower lung growth and develop respiratory symptoms (Brannon and Feist 2004). They are also particularly sensitive to the rewarding properties
1
of nicotine (Dwyer et al 2009). Smoking can help cope with anxiety, improve status
amongst peers and control weight (Scottish Executive 2006) but is often a gateway to alcohol and drugs, and predicts mental health problems, including antisocial personality disorder, anxiety or depression (Mathers et al 2005).
Since Doll and Hill reported in 1954 tobacco has been related to lung cancer in adults (Odgen 2004). Smoking also increases risk of other cancers (Marks et al). Nicotine stimulates adrenaline and noradrenaline, raises blood pressure and constricts blood vessels which combined causes heart diseases and strokes (Rogers 2009). Smoking also impairs fertility in both sexes and causes premature aging (Hussein Rassool and Winnington 2004). Yet people smoke for nicotine which enhances neurotransmitters action leading to a paradox of stimulation and relaxation (Marks et al 2006). By activating beta-endorphins and dopamine nicotine improves mood but also causes physical and psychological addiction ( Brannon and Feist 2004). There is also a link between smoking and mental health: people with psychiatric disorders smoke twice as often and smoking increases mental health problem (Weitzman et al 2002).
Health risks associated with smoking are particularly serious for older people (Rowa-Dewar and Ritchie 2010), contributing to 80% of deaths. Smoking aggravates existing health problems, increases recovery time and causes breathing difficulties, osteoporosis, hearing loss, cataracts, respiratory diseases and cancer. There is an evidence that tobacco accelerates the cognitive impairment of old age and increases the risk of dementia.
Because of damaging effect of tobacco on all aspects of health, smoking prevention has been recognised as a top priority by the government (The Scottish Executive 2006). The control policy set out in Towards a Healthier Scotland includes taxation, legislation, educating, guidelines and provision of smoking cessation services (Michie 2010). The document A Breath of Fresh Air for Scotland (Scottish Executive 2004) sets a programme for the NHS to tackle tobacco among young people, pregnant women and people from deprived areas, where the smoking rates are extremely high. Tackling health inequalities and smoking prevention is supported with extra £3 million per year (Action on Smoking and Health (ASH) Scotland 2011a).
2
The government aims to protect non-smokers from second-hand smoke, create a
supportive environment for those who wish to quit and reduce costs of smoking which are over £1 billion every year (ASH Scotland 2010a). The Smoking, Health and Social Care (Scotland) Act (2005) which came into force on 26th March 2006 prohibits smoking in all enclosed public places. The legislation limits the civil liberty of smokers but is justified by the non-smokers right to health (Callinghan et al 2010). A document A Smoke-free Scotland (Scottish Government 2005) provides guidelines for NHS and local authorities on how to comply with the new legislation.
Young smokers are of a particular governmental concern. Plans of smoking prevention are discussed in documents Towards the Future without Tobacco Smoking (Scottish Executive 2006) and Scotland's Future is Smoke Free (Scottish Government 2008). The documents aim at reducing the availability, affordability and attractiveness of cigarettes in order to discourage young people from smoking. The legal actions include Tobacco (Scotland) Act (2010) which increases the minimum age for purchase of tobacco from 16 to 18, bans any retail display and sale of cigarettes through vending machines, and creates the register for tobacco retailers (ASH Scotland 2011a).
Governmental polices are supported by a charity organisation ASH Scotland and by National Health Service (NHS) Scotland. The ASH Scotland (2010b) set out ways of tackling health inequalities and reducing smoking prevalence in a document Beyond Smoke-Free. NHS Health Scotland (2010) published a guide on cessation services intended to bring together all evidence based advice. There are also guidelines for non-smokers (NHS Health Scotland 2008c) about how to avoid harm from environmental smoke and step-by-step advice for people who want to quit smoking How to stop smoking and stay stopped (NHS Health Scotland 2009).
Despite all policies Scotland has one of the highest smoking rates in Europe with more than 13,000 deaths a year (ASH Scotland 2010a). Dumfries & Galloway Smoking Cessation Strategy (NHS 2003) presents local death rate: 350 people a year. Most smokers are aware of the damaging impact of tobacco on health, yet 58% of them cannot go without a cigarette for a whole day (Odgen 2004). Tobacco is considered the most addictive drug available (Marks et al 2006).Physical addiction may not be the only reason, there seems to be many biological, psychological and social factors involved.
3
The biological explanation includes genetic predisposition and addictive properties of nicotine. Psychology interprets smoking as learned and reinforced behaviour whilst sociology sees tobacco as a social activity creating bonds (Marks et al 2006). Smoking also seems to be confined to people who live in poor circumstances, helping them to cope with stress in life. Understanding many individual factors contributing to smoking improves chances for a successful intervention.
The National Institute for Health and Clinical Excellence (NICE) guidelines recommend NHS-supported specialist cessation services (SCS) for people wishing to stop smoking -it increases the chance to quit smoking by four times (NHS Health Scotland 2010). NICE and NHS guidelines advice blending pharmacological and behavioral therapies as the most efficient strategy which allows to control both physical and psychological addiction. Even then the rates of success are not high, with one in ten smokers quitting successfully. Such services reduce number of smokers, though, and are cheaper than doing nothing. Every NHS board in Scotland has free services run by trainers holding national qualifications and offering motivational and evidence-based treatment interventions (Mills 2004). They include group, one-to-one and phone sessions.
NHS Dumfries and Galloway (2011) website provides information about services in the region which operate under the name Smoking Matters. Services are based in Castle Douglas with clinics carried out through Dumfries and Galloway. Patients may attend them through the referrals of doctors, midwifes, health visitors and practice nurses. From 2005 there is also a self-referral contact 08456026861.
Some smoking services specialise in helping pregnant women, for example 'Breathe' in Glasgow (McGowan et al 2010). It offers an evidence-based support programme over a period of 7 weeks provided by trained midwifes. There are also SCS for pregnant women in the Royal Infirmary in Dumfries (Tappin et al 2010).
Help may be also obtained from Pharmacy Smoking Cessation Services. They include initial consultation with the pharmacist, treatment over 12 week period, regular supporting appointments with trained staff and sometimes Nicotine Replacement Therapy (NHS Highland 2008). NRT can be delivered in patches, tablets, gums, inhalators and nasal sprays—all double the chances of quitting.
4
There are also phone helplines, like Smokeline in Scotland 0800 84 84 84, the NHS Smoking Helpline 0800169 0169 and Quitline 0800 002 200. They provide callers with advice and support, self-help guides and details of local NHS services. Websites available include ASH Scotland (2011b) Information Service and www.stopsmokingquit.org.uk, www.stopsmokingcentre.co.uk, www.canstopsmoking.com, www.givingupsmoking.co.uk or www.quitwithhelp.org.uk. All of them offer cessation tools, email motivators and video clips.
Smokers can also seek help in complementary therapies such as acupuncture, aromatherapy, reflexology, shiatsu or hypnotherapy treatment. Many centres offer such help, for example Hypnotherapy Glasgow (2011) or The National Smoking Cessation Institute (2011) in Glasgow. Although not recommended by NICE because of the lack of evidence on their effectiveness (NHS Health Scotland 2010), they are popular as a non-pharmacological alternative to conventional treatment (Hussein Rassool and Kilpatrick 2004).
Helping people to quit or avoid smoking is an important part of nursing practice, highlighted by WHO and International Council of Nurses (Hussein Rassol G. 2004a). Nurses care for patients whose health has been affected by smoking and participate in health education and promotion. They provide information about smoking; are trained counselors and health promoters; researchers determining the most effective ways of helping to quit, and advocates lobbying for change and improved care. Their interventions include all levels of tobacco control, prevention and cessation, described by The Royal College of Nursing (2002) as 4 A's guidelines: ask about smoking, advice on quitting and pharmacotherapy (brief interventions), NRT and medicines, assist in stopping, arrange visits or referral to specialist services. In order to be effective, nurses require knowledge on physiological and psychological effects of smoking (Whyte et al 2006) and non-judgmental approach to smokers (RNC 2002). Sound knowledge may help to understand difficulties of quitting and support the efforts.
Because they care for everyone, nurses can use their contact with patients to encourage smokers to quit. According to RNC (2002) it may be the single most important influence than a nurse can exert on the patient. Working in hospitals and community provides many opportunistic health education for patients (Whyte et al 2006). Hussain Rassool (2004a)
5
highlights that smoking is “everybody's business” and all nurses should be involved. Midwifes intervention include screening, promotion of smoking cessation and observation of babies for withdrawal symptoms. Accident and emergency nurses are involved in management of withdrawal symptoms and respiratory failures caused by smoking. General nurses will have many patients with health conditions caused by smoking. All substance misuse is a great problem in psychiatric patients who use drugs, alcohol and smoking to relieve anxiety and depression. Therefore smoking cessation and managing withdrawal symptoms is an area of psychiatric nursing. School nurses provide advice and information to young people whose high rates of smoking is a public concern. Community nurses have many opportunities to the early identification of smokers alongside brief interventions. Smoking is also area of work of occupational nurses because of misuse of tobacco common at work place resulting in accidents and absenteeism. The important role of all nurses is an early recognition of a problem, which limits damage to individuals and society. There are also specialised addiction nurses within the branch of mental health nursing (Mills 2004) and some nurses are trained to be a SCS advisers (NHS Scotland 2010).
One problems arising in nursing interventions is substance misuse amongst nurses themselves (Hussein Rassool 2004b). Smoking is thought to be related to stress at work. Research shows that nurses smoke more than doctors and psychiatric nurses--more than any other branch. RNC guidelines (2002) place a duty on all nurses, including these who are smokers, to participate in smoking cessation interventions, as giving a professional advice is an essential part of their work.
Growing awareness of tobacco impact on health as well as governmental and healthcare actions has reduced smoking rates from over 50% in 1950s to 25% in Scotland in 2010 (Public Health Information for Scotland 2010). Successful interventions aim to control physical and psychological dependency on smoking and take into account social factors. There is also an impact of economy. The costs of treating smoke-related diseases is £1.5-£2 billion while the tobacco contribution to UK economy is £7 billion (Marks et al 2006). Smokers dying prematurely also contribute to reduction of expenditures on growing elderly population. Every government attempting smoking control will face that conflict of interest.
6
REFERENCES
Action on Smoking and Health (ASH) Scotland (2010a) Up in Smoke. The Economic Cost of Tobacco in Scotland. [Online] Available: http://www.ashscotland.org.uk/policyup-in-smoke [Accessed 17 February 2011].
Action on Smoking and Health (ASH) Scotland (2010b) Beyond Smoke-free. [Online] Available: http://www.ashscotland.org.uk/policy/beyond-smoke-free [Accesses 2 April 2011].
Action Smoking and Health (ASH) Scotland (2011a) Counter Measures. Preventing Youth Smoking in Scotland. [Online] Available: http://www.ashscotland.org.uk/policy/counter-measures [Accessed 17 February 2011].
Action Smoking and Health (ASH) Scotland (2011b) Information Service. [Online], Available: http://www.ashscotland.org.uk [Accessed: 19 March 2011].
Allender, S., Balakrishnan, R., Scarborough, P., Webster, P. and Rayner, M. (2009) The burden of smoking-related ill-health in the UK. Tobacco Control. Vol. 18 (4), pp. 262-267.
Brannon, L. and Feist, J. (2004) Health Psychology. An Introduction to Behavior and Health. 5th ed. London: Thomson Wadsworth.
Blood-Siegfried, J. and Rende, E. K. (2010) The long-term effects of prenatal nicotine exposure on neurologic development. Journal of Midwifery & Women's Health. Vol. 55 (2), pp. 143-152.
Callinan, J. E., Doherty, K., Kelleher, C. (2010) Legislative smoking bans for reducing secondhand smoke exposure smoking prevalence and tobacco consumption (review). The Cochrane Library. [Online], Issue 6, pp. 1-126. Available:http://thecohranelibrary.com [Accessed 14 February 2011].
Dwyer, J. B., McQuown, S. C. and Leslie, F. M. (2009) The dynamic effects of nicotine on
the developing brain. Pharmacology & Therapeutics. Vol. 122 (2), pp. 125-139.
7
Henderson, A. J. (2007) The effect of tobacco smoke exposure on respiratory health in school-aged children. Paediatric Respiratory Reviews. Vol. 9 (1), pp. 21-28.
Hussein Rassool, G (2004a) It's Everybody's Bussiness. The Response of Health Care Professionals. In: Hussein Rassool, G. (ed) Substance Use and Misuse: Nature, Context and Clinical interventions. 3rd ed. Oxford: Blackwell Science Ltd.
Hussein Rassool, G (2004b) Prevention and Health Education. In: Hussein Rassool, G. (ed) Substance Use and Misuse: Nature, Context and Clinical interventions. 3rd ed. Oxford: Blackwell Science Ltd.
Hussein Rassool, G. and Kilpatrick, B. (2004) An Overwiew on Intervention Strategies. In: Hussein Rassool, G. (ed) Substance Use and Misuse: Nature, Context and Clinical interventions. 3rd ed. Oxford: Blackwell Science Ltd.
Hussein Rassool, G and Winnington, J. (2004) Tobacco smoking. In: Hussein Rassool, G. (ed) Substance Use and Misuse: Nature, Context and Clinical interventions. 3rd ed. Oxford: Blackwell Science Ltd.
Hypnotherapy Glasgow (2011) Hypnotherapy for Smoking Cessation. [Online] Available: www.hypnotherapyglasgow.com/phdi/p.1nsf/supppages/3597?opendocument&part=7 .
[Accessed: 20 March 2011].
Marks, D. F., Murray, M., Evans, B., Willig, C. Woodall, C. and Sykes, R. M. (2006) Health Psychology. Theory, Research and Practice. 2nd ed. London: Sage Publications.
Mathers, M., Toumbourou, J. W., Catalano, R. F., Williams, J. and Patton, G. C. (2005) Consequences of youth tobacco use: a review of prospective behavioural studies. Addiction. Vol. 101 (7), pp. 948-958.
McGowan, A., Hamilton, S., Barnett, D., Nsofor, M., Proudfoot, J. and Tappin, D. M. (2010) 'Breathe': the stop smoking service for pregnant women in Glasgow. Midwifery. Vol. 26 (3),
pp. 1-13.
8
Michie, S. (2010) Cigarettes addiction: choice and responsibility. In: All Party Parliamentary Group on Smoking and Health (2010) Inquiry into the effectiveness and cost-effectiveness of tobacco control. [Online] Available: www. ash.org.uk/APPGoct2010 [Accessed 20 February 2011].
Mills, C. (2004) Nicotine Addiction: Health Care Interventions. In: In: Hussein Rassool, G. (ed) Substance Use and Misuse: Nature, Context and Clinical interventions. 3rd ed. Oxford: Blackwell Science Ltd.
National Health Service Dumfries and Galloway (2003) Dumfries and Galloway Smoking Cessation Strategy. [Online] Available: www.nhsdg.scot.nhs.uk/dumfries/.../Smoking%20Strategy%20Final%20Version%20Jan03.pdf [Accessed 20 February 2011].
National Health Service Scotland (2008c) Passive Smoking: Unclouding the Issue. Edinburgh: NHS Scotland.
National Health Service Highland (2008) Community Pharmacies Offer Smoking Cessation Services. [Online] Available: www.nihshighland.scot.nhs.uk/News/Pages/CommunityPharmaciesOfferSmokingCessationServices.aspx [Accessed: 13 April 2011]
National Health Service Scotland (2009) How to Stop Smoking and Stay Stopped. Edinburgh: NHS Scotland.
National Health Service Dumfries and Galloway (2011) Smoking Matters. [Online] Available: www.nhsdg.scot.nhs.uk/dumfries/10640.htm. [Accessed: 19 march 2011].
NHS Health Scotland, ASH Scotland, RCGP Scotland, Healthier Scotland (2010) A Guide to Smoking Cessation in Scotland. Edinburgh: NHS Health Scotland.
National Smoking Cessation Institute (2011) Hypnotherapy and Aromatherapy Sessions. [Online] Available: www.national-smoking-institute.org/index2.php. [Accessed: 19 March 2011].
9
Odgen, J. (2004) Health Psychology. A Textbook. 3rd ed. Maidenhead: Open University Press.
Public Health Information for Scotland (ScotPHO) (2010) Smoking Prevalence Health in Scotland: Simple Projections to 2010. [Online] Available: www.scotpho.org.uk/nmsruntime/saveasdialog.asp?lID=7998&sID...[Accessed: 13 April 2011].
Robinson, J. and Kirkcardy, A. J. (2007) Disadvantaged mothers, young children and smoking in the home: Mothers' use of space within their home. Health & Place. Vol. 13 (4), pp. 894-903.
Rogers J. M. (2009) Tobacco and pregnancy. Reproductive Toxicology. Vol. 28 (2), pp. 152-160.
Royal College of Nursing (2002) Clearing the air 2. Smoking and tobacco control – an updated guide for nurses. London: Newgate Press.
Rowa-Dewar, N. and Ritchie, D. (2010) Smoking cessation for older people: neither too little nor too late. British Journal of Community Nursing. Vol. 15 (12), pp. 578-582.
Scottish Executive (2004) A Breath of Fresh Air for Scotland. Improving Scotland's Health :
the Challenge Tobacco Control Action Plan. Edinburgh: The Scottish Executive.
Scottish Executive (2006) Towards a Future without Tobacco. The Raport of the Smoking Prevention Working Group. Edinburgh: Scottish Executive.
Scottish Government (2005) Smoke-Free Scotland – Guidance on Smoking Policies for the NHS, Local Authorities and Care Service Providers . [Online] Available:
www.scotland.gov.uk/Publications/2005/12/21153341/33417 [Accessed: 17 February 2011].
Scottish Government (2008) Scotland's Future is Smoke Free: a Smoking Prevention Action Plan. Edinburgh: The Scottish Government.
10
Smoking, Health and Social Care (Scotland) Act (2005) [Online] Available: htpp://www.legislation.gov.uk/asp/2005/13/contents [Accessed: 13 April 20011].
Stanton, H. J., Martin, J., Henningfield, J. E. (2005) The impact of smoking on the family. Current Paediatrics. Vol. 15 (7), pp. 590-598.
Tager, I. B. (2008) The effect of the second-hand and direct exposure to tobacco smoke on asthma and lung function in adolescence. Paediatric Respiratory Reviews. Vol. 9 (1), pp. 29-38.
Tappin, D.M., MacAskill, S., Bauld, L., Eadzi, D., Shipton, D. and Galbraith, l. (2010) Smoking prevalence and smoking cessation services for pregnant women in Scotland. Substance Abuse,Treatment, Prevention, and Policy. Vol.1 (5) pp. 2-10.
Todd, A. M. (2003) Barriers to smoking cessation in pregnancy: a qualitative study. British Journal of Community Nursing. Vol. 8 (2), pp. 56-64.
Weitzman, M., Byrd, R. S., Aligne, A. and Moss, M. (2002) The effect of tobacco exposure on children's behavioral and cognitive functioning: Implications for clinical and public health policy and future research. Neurotoxicology and Teratology. Vol. 24 (3), pp. 397-406.
Whyte, R. E., Watson, H. E. and McIntosh, G. (2006) Nurses' opportunistic interventions with patients in relation with smoking. Journal of Advanced Nursing. Vol. 55 (5), pp. 568-577.
World Health Organisation (2009) WHO Report on the Global Tobacco Epidemic,2009: Implementing Smoke-Free environments. [Online] Available:
http://www.who.int/tobacco/mpower/en [Accessed: 13 April 2011]