Dr Peter Saul welcomes the new NICE guidance on brief interventions and referral for smoking cessation
Smoking is still the main cause of preventable illness and early death in this country. Because of its clinical importance, reflected by the indicators in the QOF, determining a patient's smoking status and taking appropriate action already has a high priority in many GP consultations.
The recent NICE guidance Brief interventions and referral for smoking cessation in primary care and other settings1 lays down a useful strategic framework that describes effective clinical approaches to this issue.
This is the first public health intervention guidance developed by NICE. GPs and other primary healthcare professionals should not be put off by the public health label because it is a helpful document directed as much at ordinary GPs as public health professionals or managers.
Unlike NICE technology appraisals it does not examine or make recommendations concerning therapeutic interventions, consequently it needs to be read in conjunction with the earlier technology appraisal on treatment.2 The advice offered and pathways outlined serve as a useful template for GPs and practice nurses as well as others who may be advising smokers.
A total of nine recommendations are made but these can be distilled to a few core elements:
- smokers should be identified and advised to stop
- brief interventions backed up, if necessary, by pharmacotherapeutic measures may be used
- motivated individuals should be referred for more intensive support, e.g. to NHS stop smoking services.
The recommendations should have support from commissioners and management, and be backed by adequate information systems that track patients' smoking habits. Practice IT systems are usually well suited to support these information needs. In our practice we use computer-based templates to help with data collection, and with some systems the need to determine smoking status will be flagged during a consultation.
Most useful to GPs and practice staff is the algorithm that defines how and when to make brief interventions, for it is these that are likely to prove most useful in busy clinical settings. I particularly liked the simplicity of finding out merely if an individual is ready to attempt quitting, rather than determining their position on a 'stages to change' model.3
I am also pleased that we are not expected to push reluctant patients to quit, unlike more forceful American guidance.4 Instead the NICE guidance recommends that the offer of help should be left open for those smokers who are not ready to stop. These patients should be reviewed annually.
This guidance should provide useful support to ensure commissioners adequately fund local stop smoking services and encourage effective cross-professional working between health and social care.
I certainly now have reassurance that my approach to smokers in the surgery has been on the right lines. Previously I have used gentle probing whenever I come across a smoker. Support is always offered and the individual is pointed in the direction of the smoking cessation service.
This guidance has allowed me to formalise the 'management map' in my mind. Even brief interventions take precious time, but can be very useful. As a PCO board member it serves as a primer to question local support for smoking cessation to see if these measure up to the standards set by this appraisal.
- National Institute for Health and Care Excellence. Brief interventions and referral for smoking cessation in primary care and other settings. NICE Public Health Intervention Guidance No. 1. London: NICE, 2006.
- National Institute for Clinical Excellence. Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation. NICE Technology Appraisal Guidance. No. 39. London: NICE, 2002.
- DiClemente CC, Prochaska JO, Fairhurst SK et al. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol 1991; 59(2): 295-304.
- A clinical practice guideline for treating tobacco use and dependence:A US Public Health Service report. The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. JAMA 2000; 283(24): 3244-54.