Jennifer Percival highlights the importance of brief interventions in assisting smoking cessation and the vital role of the primary healthcare team in implementation
Smoking is the leading cause of preventable death and disease in the UK,1 killing more people than alcohol, obesity, road accidents, and illegal drugs combined.2
Although the overall prevalence of smoking has declined since the 1960s, it is still alarmingly high among 20–34 year olds (including pregnant women), members of some minority ethnic communities, and people from lower socioeconomic groups.1 Over half the difference in the risk of premature death between upper and lower social groups is accounted for by differences in the prevalence of smoking.3
Healthcare practitioners based in deprived areas will regularly see the devastating effects of a premature death caused by tobacco use. Reducing smoking, especially among socially deprived groups, is the number one public health priority.
Does advice encourage people to quit?
Previous guidance from NICE on encouraging patients who smoked to quit emphasised the importance of offering two types of support to achieve the greatest population health benefit: the first was to give opportunistic, brief advice to encourage all smokers to quit and to point them to effective treatments that could help; the second was to provide specialist services for those who required help to stop. The first option reached a wider population; the second had a lower reach, but a greater success rate.1
The evidence for the effectiveness of brief interventions and referral for smoking cessation has been reviewed in the NICE guideline Brief interventions and referral for smoking cessation in primary care and other settings, and it is now thought that brief advice could be key in persuading more smokers to try to stop.1
Evidence shows that advice from doctors helps people who smoke to quit.1 Even when doctors provide brief, simple advice about quitting smoking, it increases the likelihood that someone who smokes will give up successfully and remain a nonsmoker 12 months later.4 More intensive advice may result in slightly higher rates of quitting. Providing follow-up support after offering the advice may also increase the quit rates slightly.4
The guideline from NICE on brief interventions makes several key recommendations for general practice staff:1
- all patients who smoke should be advised to quit—ask those not ready to stop to consider the idea and seek help in the future; link advice to their medical condition if appropriate
- be sensitive to the individual’s preferences and how ready they are to make a quit attempt
- GPs (and all other healthcare professionals, including secondary care clinicians, dentists, and pharmacists) should take the opportunity when patients consult for other reasons to offer referral to stop-smoking services, or, in case of unwillingness to use these services, pharmacology in line with NICE guidance (see later) and support—record smoking status and review annually
- practice nurses and those in community care should reinforce stop-smoking advice
- smoking cessation policies and practices should be reviewed by SHAs, PCTs, hospital trusts, local authorities, and local community groups
- cessation advice and support should be made available in community, primary, and secondary care settings—target hard to reach and deprived communities, including ethnic groups
- a system should be set up to monitor recording of occasions when advice is given to patients, the nature of the advice, and patient response—ensure healthcare professionals can access information on the current smoking status of their patients.
Making interventions with people who smoke
Incorporating the new NICE guideline Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities5 into everyday clinical work is essential, as over 9 million British adults, approximately 22% of the population, currently smoke.6 Many smokers are regular users of the NHS and it is vital that their habit is discussed. Everyone from the receptionist to the GP has a part to play, and nurses play a key role alongside GPs in implementing guidance and practising evidence-based medicine. As one in two smokers will die prematurely from the habit, this is a ‘team activity’ that is guaranteed to save lives. Saying nothing may be translated by the patient to mean ‘No-one said anything about my smoking—it cannot be that important’.
An interactive display set up in the waiting area can draw attention to the smoking cessation services available, and a range of NHS advice leaflets on quitting are available for people to take away. Offering carbon monoxide monitoring can motivate smokers to make a quit attempt, and these machines may be borrowed from the NHS Stop Smoking Services. A local audit will help to identify a target group for mailing, who can be invited to attend for help in quitting.
The Quality and Outcomes Framework (QOF) of the GMS contract has two clinical indicators for smoking: points are awarded for recording a patient’s smoking status; and providing cessation advice or referral to a specialist service (see Box 1).7
Table 1: Smoking indicators
The percentage of patients with any or any combination of the following conditions: CHD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses, whose notes record smoking status in the previous 15 months
The percentage of patients with any or any combination of the following conditions: CHD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses, who smoke, whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months
The importance of auditing
As stopping smoking is the single most effective thing a person who smokes can do to improve their health, NICE recommends that practices audit the practice population to reveal local trends, and it has provided audit criteria on the website for this purpose. The results will help to identify the groups to target in an effort to address their health inequalities; for example, a target group can be mailed and invited to attend for help in quitting.
What is an effective ‘brief intervention’?
Brief interventions involve staff providing opportunistic advice, discussion, negotiation, or encouragement to quit and referral to more intensive treatment, where appropriate. These interventions can be delivered by any of a range of primary and community healthcare professionals, typically in less than 10 minutes. Figure 1 demonstrates a simple and time-effective brief intervention.
Brief interventions may include one or more of the following:
- an assessment of the individual’s commitment to quit
- pharmacotherapy and/or behavioural support
- simple opportunistic advice
- provision of self-help material, NHS leaflets or booklets
- referral to more intensive support such as the NHS Stop Smoking Service.
The support that nurses can provide will be influenced by a number of factors, including the individual’s willingness to quit, how acceptable they find the intervention, and previous quit methods they have tried. Many nurses have received training in implementing brief interventions and offering non-judgmental advice.
Figure 1: A simple and time-effective intervention for smoking cessation in general practice: a 30-second approach*
*This algorithm has been adapted from: Smoking Cessation Action in Primary carE (SCAPE) taskforce. Challenging nicotine addiction: a report investigating current attitudes at the frontline of smoking cessation. London: SCAPE, 2001.
Overcoming challenges to implementation
Addiction to nicotine is the reason people find it hard to stop smoking. Fear of failure or a history of unsuccessful past attempts can all increase a smoker’s resistance to change. If a smoker says they have cut down, they should be asked ‘what made you decide to do that? Do you have plans to stop altogether? If so, when?’
It is not unusual for a healthcare professional offering help to find themselves engaged in a verbal ‘ping pong’ match. The professional gives great tips, advice, and suggestions, only to have the smoker reject them. This can be frustrating. Instead of providing advice, they can start by asking questions like: ‘What have you already tried?’ ‘What challenges are you expecting?’ and ‘What can you do about this?’
If advice is sought, it should be offered in a menu format, a style that will help the smoker to develop their own coping strategy; for example:
- ‘Many people have found the following helps …’ followed by quitting tips
- Close with ‘Would any of these ideas work for you?’
Providing a treatment product to help a smoker overcome their addiction to nicotine is vital. Smoking cessation advisers and healthcare professionals may recommend and prescribe nicotine replacement therapy (NRT), varenicline, or bupropion as an aid to help people quit smoking. They should also offer advice, encouragement, and support, or a referral to a smoking cessation service.
Before being prescribed drugs to assist with quitting, the smoker should agree to abstinent-contingent treatment. He or she will commit to a target stop date by which they will have stopped smoking. Their prescription will last until 2 weeks beyond the target stop date, which will normally be after 2 weeks of therapy with NRT, or 3–4 weeks for varenicline or bupropion. The difference in length of treatment allows for different administration methods and mode of action. After that time, patients are reassessed and repeat prescriptions should only be issued to those who can demonstrate their attempts to stop smoking are continuing.5 This advice supersedes the NICE Technology Appraisal Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation.
Public health campaign
The Department of Health runs a mass media public health campaign using a combination of TV, radio, and newspaper advertising to encourage people to stop. One of the pack messages even says ‘Your doctor or pharmacist can help you stop smoking’. Practitioners can ask patients who smoke what they think when they see these messages or when watching the current hard-hitting television campaign depicting children copying their cigarette-smoking parents. Posters, leaflets, and stop-smoking guides are available in bulk free of charge from the NHS to healthcare professionals. Visit www.nhs.uk/gosmokefree or call NHS Smoking Helpline (0800 169 0 169) to order a supply for your surgery.
Towards a smoke-free future
The smoker’s world is changing fast and public opinion is in favour of even more restrictions. In 2007, enclosed public places and workplaces became smoke-free and the age when tobacco could legally be bought was raised to 18 years. In October 2008, hard-hitting graphic picture warnings will appear on all tobacco products produced for the UK market.8 Changes like these encourage people to stop smoking and practitioners should use them to their advantage.
It is not easy being a smoker today, and healthcare professionals should take every opportunity to get patients to open up about the difficulties, and ensure they know about the world class support to quit that is on offer. Several questions can be put to them:
- how has the ‘ban’ affected you?
- how do you feel these days when going outside to smoke?
- can you see yourself ever going ‘smoke-free’? If so when?
- what would have to happen first to enable you to give up smoking?
New consultation on the future of tobacco control
A public consultation on further regulation of tobacco products was launched in May 2008 by the Department of Health. The Consultation on the future of tobacco control includes suggestions to end the display of tobacco products at the point of sale and stopping access to vending machines.8 This is a full public consultation that will be open for responses from any interested parties until 8 September 2008. The consultation can be downloaded at: www.dh.gov.uk/liveconsultations.
All health professionals need to support and respond to this consultation as the fight is far from over. We need to influence the 9 million smokers in the UK to change their habits if we hope to bring an end to the death and disease caused by tobacco.
- Differences in smoking rates between higher and lower socioeconomic groups account for half of the difference in premature death rates
- Smoking cessation advice is one of the simplest methods of reducing health inequalities
- Thanks to the QOF, practices hold detailed records of patients’ smoking status that could be used to target interventions
- Pharmacotherapy can help assist smoking cessation on an ‘abstinent-contingent’ basis
- Drug tariff prices:
- nicotine replacement patch = c. £100 for a 10-week coursea
- varenicline course of treatment = £163.80b
- bupropion = c. £80 for 8-week coursea
- National Institute for Health and Care Excellence. Brief interventions and referral for smoking cessation in primary care and other settings. Public Health Intervention Guidance No.1. London: NICE, 2006.
- Action on Smoking and Health. Smoking statistics: Illness and death. http://old.ash.org.uk/html/factsheets/html/fact02.html
- Jarvis M, Wardle J. Social patterning of individual health behaviours: the case of cigarette smoking. In: Marmot M, Wilkinson R, eds. Social Determinants of Health. Oxford: Oxford University Press, 1999.
- Stead L, Bergson T, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2008 (2): CD000165.www.cochrane.org/reviews/en/ab000165.html
- National Institute for Health and Care Excellence. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. Public Health Guidance 10. London: NICE, 2008.
- National Statistics. General Household Survey 2006—Smoking and drinking among adults, 2006. Office for National Statistics: Newport, 2006.
- British Medical Association. www.bma.org.uk/ap.nsf/Content/focusQOF0308
- Department of Health. Consultation on the future of tobacco control. London: DH, 2008.G