Smoking cessation poses particular challenges during Covid-19

Smoking cessation is challenging at the best of times. It is particularly challenging during Covid-19 when it might be argued that there is an additional stress burden on many people, if not most of society. And as we know, smoking can be a method to alleviate stress in our lives, though this method is well known to be maladaptive in nature, for its costs far exceed its benefits.

Nevertheless, it would be remiss of us to overlook the reasons why people smoke, besides the physiological addiction of nicotine. There is joy in the habit. There is also benefit derived from the sheer act of smoking.

Not only can it be a highly social activity, an act executed where people congregate, but also an act that requires one to draw breath over an extended series of seconds, and exhale, slowly and with some sense of control. In many ways, this could be describing an act of mindful breathing, a relaxation method as it were. And so it is that smoking a cigarette is argued to encapsulate a series of relaxation exercises, as well as delivering an addictive nicotine hit, which is the very essence of a double-edged sword.

Prevalence of smoking in Ireland
Ireland has traditionally had relatively high levels of cigarette smoking, over many decades. There are two main indices to calculate the prevalence of smoking in Ireland. One of these is the Health Service Executive (HSE) ‘tracker’ survey, which has been operating since 2002. It is done on a quarterly basis, by phone, and includes about 4,000 people per year. The other method is the Healthy Ireland (HI) survey which commenced more recently, in 2015, and it is a face-to-face household survey that samples over 7,500 people annually.

There are also some differences in the way both surveys ask the question, but both surveys indicate an underlying downward trend in smoking prevalence in Ireland, over recent years, with upward trends in the use of e-cigarettes and those rolling their own tobacco versus those purchasing conventional tobacco products.

In 2005, smoking prevalence was estimated as being 24 per cent of the general population. This has steadily reduced year on year and in 2020 the estimated prevalence of smokers stood at 15.4 per cent of individuals in society. An estimated 18 per cent of 18-24 year olds report cigarette smoking.

This increases to 21 per cent of 25-34 year olds and falls back to just under 19 per cent of 35-44 year olds before decreasing further in the older age categories.1 It has also been noted that smoking is disproportionately prevalent in disadvantaged socio economic groups,2 with the rate of smoking among manual labourers and those in unskilled jobs, being more than double the rate of it amongst skilled professionals. Here are some stark facts in relation to smoking in the Irish context.

Smoking facts:

• Smoking kills: one in every two smokers will die from a tobacco-related disease.
• Smoking is known to take an estimated 10 to 15 quality years off a person’s life.
• Every cigarette someone smokes is estimated to take five and a half minutes off their life.
• Every six and a half seconds someone in the world dies from smoking, equating to approximately 1.5 million people per year.
• Most smokers (83%) are reported to regret starting smoking and, when asked, they say they would not smoke if they had the choice again.
• There has been a significant increase in ‘roll your own’ tobacco since 2003 (3% to 30%).
• In Ireland, smoking is the leading cause of avoidable death.
• Nearly 6,000 people die in Ireland each year from the effects of smoking and thousands of others suffer from smoking-related diseases.1

Government Strategy on Tobacco Control
The Tobacco-Free Ireland (TFI) Policy document was developed by the Department of Health in 2013.

This government strategy (2013 – 2025) has a number of cross-governmental actions which are based on the six national standards of the World Health Organization (WHO) report on the Global Tobacco Epidemic 2008. This report outlines the MPOWER package i.e. six of the most important, effective and evidenced-based tobacco policies, listed here:

1. Monitoring of tobacco use and prevention policies;
2. Protecting people from second-hand smoke;
3. Offering help to people who want to quit;
4. Warning of the dangers of tobacco;
5. Enforcing bans on advertising, promotion and sponsorship; and
6. Raising taxes on tobacco.

The direction given in this policy report seeks to de-normalise tobacco within Irish society, reduce initiation rates, assist smokers to quit, protect non-smokers, especially children, from the effects of second-hand smoke, by building a stable policy and legislative framework.

The final (sixth) direction is interesting in the sense that over €1bn in excise revenue is raised for the Exchequer, per annum, from cigarette sales.

Revenue increases on cigarettes are believed to result in two-fold benefits: firstly, it is almost certain that there will be more revenue for the Exchequer, which is also known to offset the cost of providing healthcare for tobacco smoking-related conditions (though one might suggest this is slightly offset by rising numbers turning to cheaper rolling tobacco options); and additional tax increases on cigarettes is also associated with a reduction in the numbers of people smoking.3

Smoking Cessation during COVID-19
Everyone and their mother knows that quitting cigarettes is a good thing to do. It is a major risk factor for lung disease and premature death and it’s safe to say that all healthcare professionals and the health systems within which they work, recommend quitting smoking if all possible. The reasons for this are multiple but not only does it reduce the financial burden on the State to treat the consequences of smoking-related disease, but quitting benefits people who do so on an individual level in terms of their immediate health gains, increased chance of longevity, and increased quality of life years.

Research from Respiratory Medicine suggests that those with mild to moderate chronic obstructive pulmonary disease (COPD), who quit, achieve normalisation of lung function decline within one year of quitting cigarettes.4

Furthermore, the risk of heart attack and stroke declines within one month as does the risk of associated disease. After one year, the risk of coronary heart disease drops to half that of a current smoker and lung function will have reached normal levels.

There are also additional benefits to quitting, such as, improved taste and smell, improved bodily tissue healing, whiter teeth (for the vain among us) and improved lung function.

It is also believed, though not known for sure, that a smoker is at increased risk of more severe Covid-19 disease, as per Centre for Disease Control (CDC) advice. The World Health Organization (WHO) also found a “statistically significant association between smoking and severity of Covid-19 outcomes amongst (1,726) patients”, which suggests smoking is a risk factor for more severe disease,5 though it is important to say that correlation is not necessarily causation.

Nevertheless, it seems prudent to consider regular cigarette smoking as an additional risk factor for Covid-related morbidity.

Support
Quitting smoking is challenging, but it is possible. There are plenty of resources to help a patient quit if they are in the contemplative mode of mind to do so.

There are plenty of reasons to quit smoking and a host of resources to help, but the decision to do so must come from the person themselves.

Nevertheless, motivational interviewing techniques can be a helpful, non-judgemental approach for professionals to use when encouraging a person to operationalise an intent they might have to quit.

To this end, it might be helpful to encourage a person’s reason to quit as being anchored, constructively and meaningfully, in their values (‘to be healthy’, ‘to be around longer for their kids, spouse, or grandchildren’ etc rather than the reason being to simply sacrifice a vice).

Once a person decides to quit, or is on the cusp of doing so, there are various options and choices to avail of, between smoking helplines, nicotine replacement therapies, support services and online resources.

In terms of therapeutics, nicotine replacement therapy is recommended by the HSE whereas e-cigarettes are not, given the lack of long-term data on health outcomes.

However, there is a growing opinion that ‘vaping’ as it has become called, is preferable to smoking itself and so clinical judgement might be useful in helping to steer someone away from an addictive habit well known to cause significant morbidity and mortality, in terms of what actually might effect change for the individual concerned.

Information
Should it be of any help, this is a useful resource with plenty of information and guidance: https://www2.hse.ie/quit-smoking/

Dr Damien Lowry is a Chartered member of the Psychological Society of Ireland, who has worked in hospital psychology since 2004 and he also works in private practice.

References

1. HSE tobacco control research in Ireland website: https://www.hse.ie/eng/about/who/tobaccocontrol/research/smoking-in-ireland-2020.pdf (accessed Febaruary 26, 2021).
2. Central Statistics Office Ireland report on Socio-economic group and social class available at: https://www.cso.ie/en/media/csoie/newsevents/documents/census2016summaryresultspart2/Chapter_6_Socio-economic_group_and_social_class.pdf (accessed on February 26, 2021).
3. Revenue Ireland documents regarding tobacco consumption and revenue: https://www.revenue.ie/en/corporate/documents/research/tobacco-market.pdf (accessed February 26, 2021).
4. Kotz D, Wesseling G, Aveyard P, & van Schayck OCP. Smoking cessation and development of respiratory health in smokers screened with normal spirometry. Respiratory Medicine. 2010. Vol 105(2): 243-9. DOI: https://doi.org/10.1016/j.rmed.2010.07.010.
5. World Health Organisation (WHO) briefing on Smoking and COVID-19. Accessed February 26, 2021: https://www.who.int/news-room/commentaries/detail/smoking-and-covid-19.