As we enter 2021, it is essential that our profession reflects on the lessons learnt, and the opportunities and challenges we have faced to be able to actively respond to a world focused on COVID-19 recovery. The SARS-CoV-2 pandemic has dominated governmental and healthcare systems across the globe, with nations fighting to protect their populations and save the vulnerable from severe illness and death. What has become increasingly apparent is the role of non-communicable diseases (NCDs) in fuelling the fire of the virus.
The World Health Organization (WHO) (2020) has identified a decade of underinvestment in the prevention, early diagnosis, screening, treatment and rehabilitation for NCDs, which has significantly reduced the momentum of progress in curbing the NCD epidemic. This, combined with the current pandemic, has created a deadly interplay. People with NCDs, which disproportionately affect those from more disadvantaged communities and groups, are more vulnerable to becoming severely ill or dying from COVID-19.
According to a recent study published in The Lancet, which analysed the findings from the Global Burden of Disease Study 2019 (Murray et al, 2019), NCDs now make up 88% of the overall disease burden in the UK. The five leading causes of death from NCDs in 2019 were:
For all these NCDs, tobacco smoking is a leading or significant risk factor (Murray et al, 2019).
Smoking harms nearly every organ of the body. It causes respiratory disease, cardiovascular disease, lung cancer and many other cancers. It significantly raises the risk of developing type 2 diabetes, eye disease and dementia. 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. Exposure to second-hand smoke (passive smoking) can lead to a range of diseases, many of which are fatal, with children especially vulnerable to the effects (Public Health England (PHE), 2015a).
Prevalence
Significant progress has been made in recent decades in driving down smoking rates in England. However, nearly 6 million adults continue to smoke (Office for National Statistics, 2020), with prevalence concentrated among more disadvantaged communities and groups.
Smoking accounts for around half of the difference in healthy life expectancy between the most and least deprived communities in the country. People with poor mental health die on average 10–20 years earlier than the general population, and smoking is the biggest cause of this reduction in life. A joint study by the Royal College of Physicians and the Royal College of Psychiatrists (2013) found that in England one third of cigarettes are smoked by people with a mental health condition.
Smoking remains the largest preventable cause of illness and premature death in England, and was responsible for 74 600 deaths in 2019. In 2019-2020, an estimated 506 100 hospital admissions were attributable to smoking, an increase of 10% on 2009-2010 (NHS Digital, 2020). One in four patients in hospital beds are smokers. Smokers also see their GPs 35% more than non-smokers. Treating illness caused by smoking costs the NHS in England about £2.4 billion a year. Combined with additional costs to social care and lost productivity due to smoking, the estimated annual cost to society is £12.5 billion (Action on Smoking and Health, 2019).
Stopping smoking at any time has considerable health benefits, including for those with a pre-existing smoking-related disease. In the time of the COVID-19 pandemic, this is more important than ever. Although evidence on the impact of smoking on SARS-CoV-2 risks remains unclear (Simons et al, 2020), what is clear is that quitting 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 and care system.
Interventions
The Government has a stated ambition to achieve a smoke-free society in England by 2030 (Cabinet Office and Department for Health and Social Care, 2019), defined as adult smoking prevalence of 5% or less, and this is a top strategic priority for PHE.
Supporting smokers in contact with the healthcare system to quit is a prevention priority in The NHS Long Term Plan (NHS England and NHS Improvement, 2019), and by 2023–2024 all people admitted to hospital who smoke will be offered NHS-funded tobacco treatment services, based on the Ottawa Model for Smoking Cessation (this is a hospital initiated smoking cessation programme that includes systematic identification of smokers, provision of behavioural support and pharmacotherapy, and follow-up upon discharge) (Mullen et al, 2017). The model will also be adapted for expectant mothers and their partners, with a new smoke-free pregnancy pathway including focused sessions and treatments. A new universal smoking cessation offer will be available as part of specialist mental health services for long-term users of specialist mental health, and in learning disability services.
Primary care is a crucial part of the prevention pathway and will typically reach a larger number of generally healthier and younger smokers. Cost-effective, proven smoking cessation interventions can be delivered simply and quickly through primary care to help reduce the number of people who smoke.
Acting on smoking and tobacco is a principal component of PHE's All Our Health programme (PHE, 2015b), a framework of evidence to guide all health and care professionals in preventing illness, protecting health and promoting wellbeing. Smoking and tobacco: applying All Our Health (PHE, 2015a) identifies actions that health and care professionals can employ, whether working directly with the public, as a manager, or in a strategic or operational leadership role across the health and care system. It provides access to data sources, guidelines and additional training resources and is accompanied by an interactive e-learning session, which counts towards continuing professional development.
The nursing and midwifery profession is front and centre in the drive to make smoking obsolete in England. Smoking is not a lifestyle choice but a dependency, with many smokers needing help to quit. Supporting a smoker to quit is one of the most effective ways health and care professionals can help improve a person's health. Over half of current smokers say that they want to quit, with 1 out of 5 intending to do so within 3 months (PHE, 2015a).
Currently, around half of all smokers in England who try to quit do so unaided, using willpower alone, despite this being the least effective method (University College London, 2020). Prompts by health professionals are one of the most important triggers for a quit attempt and the success of these attempts can be significantly increased by helping patients identify and access appropriate quit aids and further support (PHE, 2018):
‘Although evidence on the impact of smoking on SARS-CoV-2 risks remains unclear, what is clear is that quitting brings rapid improvements in respiratory and cardiovascular health, reducing the risk of acute events that require hospital admission’
Opportunities
The National Centre for Smoking Cessation and Training (2021) provides a free online training module on how to deliver very brief advice (VBA) on smoking. This evidence-based intervention should be standard practice in all health and care settings. All nurses and midwives should be offering VBA as part of routine care and should know about locally available specialist support and how to refer smokers.
Within every crisis lies opportunity. WHO has made clear that the execution of a forward-looking strategy inclusive of NCDs is required to build back better and reach Sustainable Development Goal 3.4 on NCDs. As the largest health and care professional workforce across the globe, nurses are ideally positioned to lead a fundamental shift in the way that systems focus on preventing, protecting and promoting the public's health.
Tobacco accounts for more than 8 million deaths globally every year (WHO, 2019). The UK is already a world leader in comprehensive action to tackle the devastating harm tobacco causes to individuals, communities and society. Working together globally, nationally, locally, at organisational level and individually, we must take this to the next level to improve the population's health and, most importantly, address unacceptable inequalities.
Adriana Blanco Marquizo, head of the Secretariat of the WHO Framework Convention on Tobacco Control, sums it up as follows: ‘Addressing NCDs, their risk factors, and tobacco use in particular must be an integral part of the immediate COVID-19 response and recovery as well as of part of building-back-better strategies to achieve the 2030 Agenda for Sustainable Development’ (Blanco Marquizo, 2020).