Smoking and Rheumatoid Arthritis: how to deliver brief smoking cessation advice

Smoking and Rheumatoid Arthritis: how to deliver brief smoking cessation advice

Offering brief advice to stop smoking is the most cost-effective and clinically proven preventative action a healthcare professional can take 1, 2. It is important that people with Rheumatoid Arthritis are aware of the impact that smoking can have on their condition. This booklet will support you and your team to help more of your patients give up smoking, by looking at five key areas: Rheumatoid Arthritis and smoking: what you need to know Many RA patients are not aware that smoking increases the risk of RA, and that continued smoking interferes with the treatment of their RA. The facts are: n Heavy smoking can increase the risk of developing RA by up to 100% 3. n RA patients that smoke may have a higher risk of cardiovascular disease 4, 5. n Smoking can weaken the effectiveness of RA medication 6, 7. n RA may be more severe in smokers than non-smokers 8. n Quitting is recommended for everybody, but provides particular health benefits to patients with RA 3-8. How to make your practice more effective Why you should discuss smoking Treatment options Support and resources Giving the right advice to your patients will help them to better manage their condition. Offering brief advice on smoking cessation can be challenging, so please use the information in this guide to help you to engage with your patients. Smoking costs lives Smoking is estimated to cost the NHS in England up to 1.7 billion a year 9. The yearly cost of smoking-related disease to the NHS in Scotland is around 271 million 10. Smoking and RA case study

Why give advice to your RA patients on smoking? Nearly two-thirds of smokers want to quit, but less than half make a quit attempt in any given year 11. Brief advice only takes 30 seconds which could change a smoker s life, and prevent one premature death 14. All healthcare professionals can deliver brief advice on smoking cessation. WHY Smokers that were offered smoking cessation support were: 1. more likely to attempt to stop 2. more likely to use stop smoking medication (on prescription and over the counter) 3. more likely to use a Stop Smoking Service 12. The following Numbers Needed to Treat (NNT) for various routine preventative interventions demonstrate why brief advice to stop smoking is called the Gold Standard of Preventive Interventions: Intervention Outcome NNT Statins Prevent one death over five years 107 15 Antihypertensives Prevent one stroke, MI or death 15 16 for severe hypertension in one year n Around 70% of smokers say they would like to stop smoking, and many have made multiple attempts to quit. Furthermore around half of smokers sought some kind of help or advice to stop smoking, this included seeking advice from a health professional 13. n Rheumatology Teams need to increase awareness of GPs about the link between RA and smoking. Rheumatology teams should work in partnership with the patient s GP to support smoking cessation. This can be done by documenting the smoking status of patients aged 15 and above, and offering brief advice to quit when the patient attends Rheumatology appointments. Antihypertensives Prevent one stroke, MI or death 700 15 for mild hypertension in one year Cervical cancer Prevent one death over ten years 1140 15 screening Brief advice Prevent one premature death* 80 15 to stop smoking Add pharmacological Prevent one premature death* 38-56 15 support Add behavioural Prevent one premature death* 16-40 15 support * Over half of all continuing smokers will die prematurely from a smoking-related disease.

How to discuss smoking with your patients Brief interventions contribute to saving lives The desired outcome is to trigger quit attempts and to prompt smokers to seek support from smoking cessation services. Questions to ask your patients: n How do you feel about your smoking? n What do you enjoy most about smoking? n What don t you like about smoking? n Have you ever thought about stopping smoking? Example dialogue: ASK: Do you smoke? Yes ADVISE: Would you like to stop? It s the best thing you can do for your health Yes No Record smoking status No n Have you ever tried to stop smoking before? What happened? n Why did you start smoking again? n What do you know about smoking and RA? n How do you think smoking affects your condition? Many services will use the AAA approach to discuss smoking. Ask, Advise and Act! It only takes 30 seconds to give brief advice to smokers using the AAA approach. ADVISE: Would you like help to stop, because the best proven way is with support from a trained Stop Smoking Advisor plus treatment ACT: Provide a smoking and RA leaflet, and emphasise that when they do want to stop, support and treatments are available that can make it much easier. HOW Treatment options The options for your patients includes providing a smoking and RA leaflet and suggesting stop smoking medication. All patients should be offered referral to the Stop Smoking Service, where they can receive a number of behavioural support sessions. Many patients opt for one-to-one support provided by the Stop Smoking Service. An intensive behavioural support programme of six to seven sessions, combined with twelve weeks of stop smoking medicine, increases the likelihood of success by up to four times 17. Please contact your local Stop Smoking Service for further information and patient referral forms. Yes ACT: Provide a smoking and RA leaflet, and ensure patient makes an appointment with a Stop Smoking Advisor and record contact details for referral. Give your patients the best chance of quitting and improving their health. They are up to four times more likely to quit successfully with NHS support than by doing it alone 17. No

Support and resources You can make a brief 30-second intervention achieve the utmost effectiveness by: n Establish a Rheumatology team stop smoking protocol that includes brief intervention and offers support for patients to quit. n Displaying promotional materials about the stop smoking support that is available*. n Having trained members of the team who can ask about smoking status routinely*. n Use Stop Smoking Service referral forms. Consider pre-printing all outpatient appointment letters with a smoking cessation referral form on the reverse. This creates an opt-out culture where patients can choose whether they want to be referred to the Stop Smoking Service or not*. The above steps communicate that your Rheumatology team thinks stop smoking support is a credible activity: n That smokers can expect to be asked about their smoking status. n That friendly help and support is available, increasing their feelings of self-efficacy in stopping smoking. n That it is okay to ask for help and support. *See opposite page for an example of how your local Smoking Service can help you to gain access and support to these resources. FREE support and resources for your Rheumatology team to use NICE recommends that all healthcare practitioners give brief stop smoking messages to all smokers. But it is not just one person s job. Pfizer can help you to ensure that your Rheumatology team and GP practice team are appropriately trained and have the necessary knowledge and skills to deliver a potentially life saving skills-based clinical intervention. We offer, free of charge: n Specialist training for health professionals or assistants to raise the issue and/or help patients quit, with regular skills update sessions. n Brief intervention training for both health professionals and non-health professional staff. n Set up and support for Rheumatology Smoking Cessation Services. n Help with promotion of Rheumatology Smoking Cessation Service. n Support for the development of a Rheumatology Smoking Cessation Pathway. n Help and advice with smoking cessation, data collection and return. n Motivational interviewing training which will enhance the way in which health professionals deliver smoking cessation advice. RESOURCES

Development and Printing funded by Pfizer Ltd, June 2011. Ref code: ENB 512d Pfizer RA A4 poster.indd 1 9/8/11 16:30:44 Smoking and RA campaign Originally developed by NHS Fife with support from Pfizer, the Smoking and RA campaign was created to raise awareness of the impact that smoking can have on the condition, and to encourage RA patients to quit smoking. The Fife RA smoking study showed that 94% of RA patients were unaware of the impact smoking had on their condition. 20% of RA patients were current smokers and most were unaware of the services available to support smoking cessation 18. The information collected before and after the campaign will be used to empower RA patients to take positive steps towards quitting. Several approaches were developed to convey the impact that smoking has on RA. The materials were then reviewed by members of the National Rheumatoid Arthritis Society (NRAS) that were smokers with RA themselves. The concept voted most appropriate was then produced in the format of leaflets and posters. The campaign was successful in raising awareness of the link between RA and smoking, and the effect of continued smoking on treatment. If you would like your Rheumatology team to implement a smoking cessation pathway you can access a toolkit of smoking cessation materials by contacting your local Pfizer representative. Smoking and Rheumatoid Arthritis: a joint problem. Rheumatoid Arthritis (RA) can dramatically affect quality of life. It is therefore important that people with RA are aware of the impact that smoking can have on the development and management of their condition. Heavy smoking increases the risk of RA by up to 100% Smoking can increase your risk of RA Smoking can lessen the effect of your treatment RA is more severe in smokers than non-smokers Quitting smoking is one of the best things you could do for your RA If you d like to quit smoking, you can get FREE help and support from your local Stop Smoking Service by calling 0800 025 3000. If you d like further information on RA and smoking, visit the National Rheumatoid Arthritis Society online at www.nras.org.uk All smokers should be advised to stop smoking and offered evidence-based support, regardless of whether or not they express a desire to stop 19. References Thank you for taking an interest in the Fife RA and smoking awareness campaign. I hope that you will find the materials that have been developed useful and that you will provide feedback to us. If you wish to audit the success of your own smoking cessation campaign I can share the questionnaires used in Fife. Email helenharris@nhs.net 1. West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax 2000;55(12):987-99. 2. Conroy M. Majchrzak N, Regan S, et al. The association between patient-reported receipt of tobacco intervention at a primary care visit and smokers satisfaction with their health care. Nicotine & Tobacco Research 2005;7(Suppl.1):S29-34) 3. Sugiyama et al. Impact of smoking as a risk factor for developing rheumatoid arthritis: A meta-analysis of observational studies: Ann Rheum Dis 2010;69:70-81. 4. Manjari Lahiri et al. Modifiable risk factors for RA: prevention, better than cure? Rheumatology 2012;51:499512 5. Ulf Müller-Ladner et al. Cardiovascular risk management in patients with inflammatory arthritis: what is good for the joint is good for the heart and vice versa! F1000 Medicine Reports 2010, 2:27 (doi:10.3410/m2-27) 6. Saevarsdottir et al. Patients with early rheumatoid arthritis who smoke are less likely to respond to treatment with methotrexate and tumor necrosis factor inhibitors: Observations from the epidemiological investigation of rheumatoid arthritis and the Swedish rheumatology register cohorts: Arthritis & Rheumatism 2011;63:26-36 7. Abhishek et al. Anti-TNF-[alpha] agents are less effective for the treatment of rheumatoid arthritis in current smokers: Journal of Clinical Rheumatology 2010;16:15-18. 8. Masdottir B. et al. Smoking, rheumatoid factor isotypes and severity of rheumatoid arthritis Rheumatology 2000; 39:1202-1205. 9. Callum C. Boyle S. and Sandford A. Estimating the cost of smoking to the NHS England and the impact of declining prevalence, Health economics, policy nd law, 6 (4), 2012, pp. 489-508. ISSN 1744-1331 10. ASH Scotland Up in smoke The economic cost of tobacco in Scotland. November 2010 11. Healthy Lives, Healthy People. A Tobacco Control Plan for England. March 2011 12. Smoking Cessation in England 2010: Findings from the Smoking Toolkit Study 13. The NHS Information Centre, Lifestyles Statistics. Statistics on Smoking 2010 14. Smoking Cessation Action in Primary Care (SCAPE) 2001 15. NHS Stop Smoking Services Service And Monitoring Guidance 2007/08 16. Bandolier 17 - Evidence-based health care 1995 17. NHS Stop Smoking services Service and monitoring guidance 2010/11 18. Harris. H et al. Success of a Smoking and Rheumatoid Arthritis Awareness Campaign in Fife, Scotland. BSR Abstract Submitted 2012 19. Department of Health: Service delivery and monitoring guidance 2011/12

Development and Printing funded by Pfizer Ltd, August 2012. Ref code: NPKAM0054