A Physiotherapist’s role in tackling smoking addiction and health inequalities

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Introduction

Welcome to this online wiki learning resource which focuses on the physiotherapists role in smoking cessation and tackling health inequalities. This has been produced by a group of 4th year physiotherapy students within Queen Margaret University as part of the module Contemporary and Emerging Issues in Physiotherapy Practice.

Cigarette smoking is the leading preventable cause of morbidity and mortality in Scotland. There are approximately 10,000 smoke-related deaths per year (ScotPHO, 2016). Indeed, smokers are putting themselves at risk of heart disease, stroke, cancers and respiratory diseases (British Heart Foundation, 2016). It is estimated that one in two smokers will die prematurely due to a smoke-related illness (Doll et al., 1994). Over the last four decades, smoking prevalence has decreased in scotland, however it remains one of the nation’s biggest health challenges. Moreover, it is not only the smokers themselves that are affected, according to WHO (2016), 10% of deaths due to tobacco smoking in the world are the result of non-smokers being exposed to second-hand smoke.

It has been designed for all different types of learners with an interactive learning experience which can be used as part of your continued professional development (CPD). It is an individual self-study resource which should take 10 hours of learning to complete.

Aims

•  To provide final year physiotherapy students with an online learning resource that will improve their knowledge regarding smoking and its addictive nature, the effects of smoking on individual’s health as well as its relationship with health inequalities 
•  To provide final year physiotherapy students with an online learning resource that will provide an understanding of the role of physiotherapists in smoking cessation, recognise evidence based smoking cessation interventions as well as the knowledge and skills required by a physiotherapist to effectively utilise these interventions.

Learning Outcomes

By the end of this wiki, you should be able to:

1. Compare & contrast health inequalities and smoking in different geographical and socio-demographical areas in the U.K.
2. Critically appraise the effects of smoking and its addictive nature
3. Critically evaluate the evidence underpinning a number of smoking cessation interventions appropriate for physiotherapists and how each intervention contributes to tackling health inequalities
4. Propose the knowledge, skills and attitudes required of a physiotherapist in order to deliver a number of smoking cessation interventions for those smokers appropriate for smoking cessation

These aims and learning outcomes have been created using bloom's taxonomy, hierarchy of learning. They are set in the creating and evaluating levels of the taxonomy to enable a higher level of learning for final year physiotherapy students and newly qualified band 5 Physiotherapists.

Behavioural Effects of Smoking

Smoking and mental health

Due to the physiological changes associated with smoking, a smoker may experience a wide range of behavioural changes.
In comparison to nonsmokers or former smokers, smokers tend to be more extroverted, tense, impulsive, depressive and anxious and tend to have characteristics linked to neuroticism, psychoticism and sensation-seeking as well as antisocial or unconventional behaviours (Rondina et al. 2007). The literature highlights evidence that smoking is linked to mental health disorders, notably depression, anxiety, panic disorders, schizophrenia, attention deficit disorder and alcoholism. Rondina et al.(2007)’s study therefore suggests that health professionals should bare these personality traits in mind when promoting smoking cessation in clinical practice. The study emphasises the importance of interdisciplinary work in order for smoking cessation to succeed.

Smoking and stress

Smokers associate smoking with stress relief even though there is no physiological proof of this. (?ref) In fact, Heishman(1999)’s paper highlighted that addicted smokers felt an increase in anxiety and stress levels after being deprived of smoking and that regular smokers can even develop these negative moods after a 30-45 minute interval between cigarettes. The study suggests that when smokers believe that their smoking relieves stress, it actually only relieves withdrawal-induced stress and negative moods due to tobacco deprivation. Effectively, smokers who are avoiding smoking are causing themselves added withdrawal stress and so the relief they experience once they smoke is not an effect on their baseline, but simply relieving them from the withdrawal induced stress (Lorist and Snel 2013). According to literature (Le Houezec et al., 1996), there is evidence that smokers can adjust their nicotine intake in order to heighten their mental functioning and/or control their mood. This therefore suggests that individuals who do this are at greater risk of dependence and of withdrawal symptoms during smoking cessation. 

Smoking and cognitive performance

According to older studies, evidence has shown that smokers show an increase in cognitive abilities. Literature (West and Hack 1991) suggests that nicotine acts specifically on improving memory scanning and interestingly, the results showed no difference between occasional and regular smokers. However, due to methodoligical problems and unclarity, the results from the literature are inconclusive. Lorist and Snel (2013), speculate whether smoking enhances performance by acting directly on the Central Nervous System (CNS) or by relieving symptoms of abstinence. They also consider whether smoking improves performance by affecting specific areas of the brain or if it affects all mental processes. Indeed, as they suggest, further research in this area is required to ascertain the effects of smoking on cognitive performance. 

Addiction

Smoking is one of the most common types of addiction, closely following caffeine and alcohol (Teeson et al. 2012). Nicotine is a highly addictive drug which is sourced in tobacco leaves and is one of the main elements in cigarettes. It alters the balance of noradrenaline and dopamine levels in the brain causing changes in mood and concentration which people find enjoyable as they feel it reduces stress and anxiety. However, once you stop smoking the noradrenalin and dopamine levels are altered again, causing increased irritability, stress and anxiety. This leaves the individual in low mood, with poor concentration levels and craving a cigarette to relieve these symptoms. New studies show the increase in cannabis smoking amongst younger generations as this is an evolving problem area at present (REFERENCE).

In recent years there has been a change in the definition of addiction as it was previously described as a behavioural problem with the words “abuse” and “dependency” interlinked with it. However these have been removed and it is now defined by the American Society of Addiction Medicine (2011) as “a chronic, relapsing brain disease that is characterised by compulsive drug seeking and use, despite harmful consequences”. Addiction is now viewed as a brain disease due to the addictive substance eg. nicotine, causing the brain to become hyper-responsive to it, thus making it very difficult for the addicted brain to then ignore. The nicotine begins this process, however the changes in the brain persist long after withdrawal from the drug making it difficult to then stop smoking as the brain craves the nicotine.

Stages of Change

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Benefits of Quitting

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Second Hand Smoking

Second hand smoking (SHS), also known as passive smoking, is the process of breathing in other people’s smoke (Cancer Research UK, 2016). SHS exposure is associated with adverse physical health issues such as heart disease, respiratory illnesses and cancer.
Evidence has shown that SHS children or adolescents are susceptible to smoking and have an increased risk of early initiation. This may explain why smoking is most prevalent in the young adult age group. Okoli et al. (2015) ‘s study has shown that SHS young adults are more likely to associate smoking with positive symptoms, such as dizziness, relaxation and high. Research also suggest that smokers may not be aware of the risks associated with SHS and how this may affect others.
Future policies/strategies should look into tackling SHS in order to decrease the likelihood of these individuals developing a nicotine dependence. (80% of SHS young adults are likely to develop a smoking addiction). This fits it to the shift of HCPs roles from acute care to preventative.

Smoking Addiction in Young Adults

Future smoking cessation policies/strategies should increase focus on the young adult age group (smoking most prevalent in this age group). Studies have shown that young adults tend to believe that health risks associated with smoking will only come later on and therefore adopt the philosophy “I will quit when I’m older” or believe that being physically active and eating a balanced diet will “compensate”, however this is untrue. In fact, research has shown that they are very much at risk of respiratory infections and impaired healing. Furthermore, young adults only consider quitting seriously once the nicotine addiction has set in and therefore find it a lot harder to quit. This therefore justifies the need for a focus of smoking cessation and prevention services on the young adult age group and why the shift from acute to preventative measures is beneficial.

Barriers and Motivators to Quit

Perceived barriers to smoking cessation

The NMRC conducted a large qualitative study looking into smokers’ perceptions of quitting. The research showed that the majority of persons would try quitting without support as a first attempt. The main theme identified by smokers for any quit attempt was willpower. However it was identified that smokers did not realise the extent of their addiction until after failing a first attempt to quit, to then develop an understanding of their addiction and realise they may need external support. The study also highlighted that smoker engaged with emotional rather than rational or logical benefits of different quitting methods. Interestingly the research showed that smokers struggled to understand the clear role of the NHS within the quitting process: they realised there was a wide range of services offered to them, however some (such as support groups) were generally viewed as unappealing. The NMRC therefore recommend that the NHS should provide a coherent programme rather than a range of methods to quit as well as presenting any relapse as a stepping-stone in their journey to a smoke-free lifestyle.

Individuals from Deprived Areas

Research showed that these individuals felt that their smoking is hard to control and were torn between thinking they need intensive measures to quit and that all they really need is strong willpower. They also expressed that they felt marginalised by society and government and that they’re addiction wasn’t regarded as serious as alcohol or drugs. The study highlighted that these individuals were not aware of the extent of services available to them, and regarded the few they knew of as expensive and ineffective, despite evidence to the contrary. The individuals even suggested smoking cessation group services as a motivator for quitting, unaware that these are already available to them.
Another barrier to smoking cessation highlighted by the study’s participants was that it was easier to have access to contraband cigarettes in these deprived areas.
So in future, in order to enable smokers to overcome their addiction, the research showed that we, hcps, must promote smoking cessation services, in a personalised non-judgemental with flexible, low-cost support.

References

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