Smoking is the largest single preventable cause of death and disability in the UK,1 responsible for more than 120 000 deaths annually and costing the NHS approximately £1500 million a year.
There is now clear evidence that effective smoking cessation support, delivered through the healthcare system, works.2 The tobacco White Paper published in December 19983 committed the Department of Health to funding, developing and monitoring nationwide smoking cessation services. Before this, smoking cessation had not been prioritised, and there was often no support in primary care for those who wished to stop smoking.
In 1996, Wyke Regis Health Centre, where I work, recognised that general practice was uniquely placed to offer smoking cessation support for the following reasons:
- Health promotion and health improvement are key objectives in primary healthcare.
- The availability of local smoking cessation training programmes meant that the practice nurse was able to offer support.
- Smoking is a contributory factor in many conditions for which patients seek advice from their GP or practice nurse.
- The average general practice has at least 2000 patients who smoke. Smokers are known to consult doctors more often than non-smokers, thus providing the ideal opportunity to tackle this most important cause of preventable death and disease.
'SmokeStop' is a group approach devised to provide support to patients wishing to give up smoking. It is coordinated and run by the practice nurse.
- To determine the smoking status of all patients on computer-held records
- To encourage behaviour change towards becoming a non-smoker by opportunistic questioning on smoking habit and thoughts about smoking, and by offering support to stop
- To have in place an accessible and ongoing programme of SmokeStop to offer patients who are ready to give up.
Although the group was run by the practice nurse, it was essential that the practice team were equally supportive in identifying smokers who were contemplating giving up smoking and encouraging them to try.
Our aims, as identified in our practice protocol (see Figure 1, below), were:
- To become more active in smoking cessation within the primary healthcare team
- To establish a smoke-free policy within the practice
- To make it known that support was available for those who are thinking of stopping
- To ensure that a clear message was given by the reception staff when dealing with enquiries, with supportive literature
- To establish roles within the practice team, i.e initial consultation with the GP raising the issue, then referral to the practice nurse for further advice and support
- To review staff training needs implied by the above and to seek appropriate training.
Patients could self-refer from information displayed in the surgery or be referred by any member of the healthcare team. Identifying the stage of behaviour change of the smoker was a key factor in recruiting participants.
A computer template was devised to record patients' smoking habits and their readiness to change, based on Prochaska's change model.4 This model describes how a person has to go through stages of pre-contemplation (contented smoker), contemplation, (concerned smoker), preparation (thinking about stopping), and readiness (planning to stop) before changing their behaviour.
|Figure 1: Wyke Regis Health Centre smoking cessation protocol and guidelines|
The group approach to smoking cessation was chosen because it was cost-effective, i.e. a number of patients could be helped in far less time in a group than in individual consultations.
For example, the average number of patients starting a group was six. The course comprised six sessions, each lasting one hour, at weekly intervals. Total practice nurse time = 6 hours. In contrast, individual appointments for six patients at half an hour a week for 6 weeks. Total practice nurse time = 18 hours.
Other therapeutic advantages of the group approach were:
- The patient feels a sense of belonging and being valued
- The patient discovers that his problems are not unique
- The patient learns, with satisfaction, that he can be of help to others in the group, sustaining motivation
- The patient benefits by hearing the experiences of other group members.
The sessions were divided into three stages (see Figure 2, below).
|Figure 2: Aims of the three stages of the group therapy sessions|
At the time of the Beacon submission in May 1999, more than 140 patients had attended the SmokeStop sessions. The results were as follows:
- 80% stopped smoking during the course for varying periods
- 15% were not smoking 3 months after their quit day.
The high relapse rate emphasises that giving up smoking is a process, and that relapsing is a natural part of that process. Most smokers don't give up the first time they try it often takes several attempts. But having attempted once, they are never again a 'contented smoker'.
Evaluation questionnaires given to the group members at the end of the course, at 3 weeks and at 3 months revealed that 100% of those who had relapsed said they would try again in the future. Many attended the course for a second and third time and were eventually successful.
The 15% long-term cessation rate showed a considerable improvement over the 3-5% cessation rate quoted by the University of York in its research paper on the effectiveness of interventions in primary care.5
The service was cheap to run and easily transferable to other practices within the primary care group (PCG).
A great deal of enthusiasm and commitment by the practice nurse was an essential part of the success of SmokeStop. Our practice was the only practice in the PCG to run a regular group and we were well known for our activities in this field.
During the next year, four open days were held at the health centre. These were attended by a variety of health professionals who wanted to run smoking cessation groups in their own locations and were looking for new ideas.
A manual was produced with aims and objectives, lesson plans and suggestions for practical activities for group sessions. Leaflets and photocopies of the literature used in the groups were made available, and the equipment used the carbon monoxide monltor and the 'smoking lung' were demonstrated. A video was shown of some of the group sessions in action.
Evaluation of the open days showed that several nurses and health visitors had started their own groups using ideas gained from our manual.
We made plans to open our doors to patients from other practices in our PCG to recruit more participants and professionals interested in helping to run the group sessions. This was the start of an integrated approach to smoking cessation at local level.
In January 1999, smoking cessation guidelines for health professionals were launched by the then Public Health Minister Tessa Jowell.6 A summary of these was published in the BMJ in January 1999.7 The guidelines were evidence based, endorsed by the professions, supported by the Government and cost effective.
The Government provided £10 million to the health action zones (HAZs) in 1999-2000, and from April 2000 all health authorities should have received monies to develop smoking cessation services, with funding until April 2003. For the first time, smoking cessation has become a core part of NHS provision.
In April 2000 a coordinator was recruited to set up a county-wide strategy for smoking cessation. This was to be a two-tier system: funding to provide intermediate support at general practice level, with an increase in access to training and one-to-one support, and a specialist service run by appointed smoking cessation specialists to establish hospital-based groups for smokers needing more intensive help to give up.
In December 2000, I was appointed one of three specialist advisors in Dorset, and so am able to recount, first hand, how smoking cessation support has evolved from the primary care-based groups to the larger, more intensive groups that are now in place.
Referrals to the specialist service are accepted from all general practices in the area and from outpatient departments and hospital wards.
Withdrawal-oriented therapy sees withdrawal discomfort as the major remedial obstacle to quitting in dependent smokers. It uses a combination of group or individual support (to boost motivation) and medication (to alleviate withdrawal discomfort).
There are extensive data on experience with and efficacy of the therapies used in the specialist clinics bupropion (amfebutamone, Zyban) and nicotine replacement therapy (NRT).8 Figures 3 and 4 (below) show a comparison of cessation rates with different therapies and level of support.
|Figure 3: Point prevalence abstinence rates at one year in a study comparing bupropion with a nicotine patch9|
|Figure 4: Twelve-month abstinence rates with different smoking cessation interventions10|
Smokers many for the first time are now seeking help in giving up smoking from their GPs. Trials show that the success of these treatments is increased with support, and the decision was made at PCG level in Dorset that these therapies would only be prescribed after referral to intermediate or specialist smoking cessation clinics.
These services must comply with the requirements for data collection laid down by each health authority. This has individual targets for the number of clients setting a quit date and those who have successfully quit for 4 weeks following the quit date.
Patients who attend the specialist clinics will also be monitored at 1 year following the quit date, if possible by carbon monoxide validation.
The results are forwarded quarterly to the Department of Health, who need to obtain robust information about the effectiveness of the investment made in these services. Table 1 (below) shows results for the last quarter April to July 2001 of the specialist returns in Dorset; 52-week quit rates are not due until December 2001.
Table 1: Specialist smoking cessation clinic returns in Dorset: April to July 2001
|Specialist clinics||Forms returned |
(patients who have set quit date)
|4-week quit rate||% quit|
The format of the specialist clinic is shown in Figure 5 (below).
|Figure 5: Format of the specialist smoking cessation clinic|
Elements of both programmes described have contributed to the success in helping smokers give up. My experience of SmokeStop and the Beacon award have fuelled my enthusiasm to continue. Many of the activities that worked well in SmokeStop are successful in the specialist clinics.
The development of the smoking cessation specialist clinics, however, has hugely increased the number of patients able to access support, use bupropion and NRT8 and successfully give up smoking.
The larger group size (up to 20 in the specialist clinics) is a major factor in creating a strong group support.
Single practice groups tend to be small in numbers at the start and, with the inevitable non-attendees during a course, make group dynamics almost impossible and in my experience hard work for the tutor. I continue to provide SmokeStop at Wyke Regis Health Centre on a one-to-one basis, with weekly appointments for up to 6 weeks.
We use the same data collection forms as the specialist clinics, which have to include a quit date and 4-week follow-up. I now encourage the use of NRT or bupropion and our quit rates are comparable to those obtained in the specialist clinics.
- Callum C. The Smoking Epidemic. London: Health Education Authority, 1998.
- Raw M, McNeil A, West R. Smoking cessation guidelines for health professionals: an update. Reprinted from Thorax 2000: 55: 987-99.
- Secretary of State for Health. Smoking Kills. A White Paper on tobacco. London, The Stationery Office, 1998.
- Prochaska J, Goldstein M. Process of smoking cessation: implications for clinicians. Clin Chest Med 1991; 12: 727-35.
- University of York. Smoking cessation: what the health service can do. Effectiveness Matters: 3(1).
- Raw M, McNeil K, West R. Smoking cessation guidelines for health prolessionals. A guide to effective smoking cessation interventions for the health care system. Thorax 1998; 53 (Suppl 5), Part 1.
- Raw M, McNeil A, West R. Smoking cessation: evidence based recommendations for the healthcare system. Br Med J 1999; 318: 182-5.
- Hajek P. Helping smokers to overcome tobacco withdrawal: an update from Br J Addiction 1989; 84: 591-8.
- Jorenby DE, Leischow SJ, Nides MA et al. A controlled trial of bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 1999; 340: 685-91.
- Time to help smokers quit. Practice Nurse Supplement. November 2000.