Smoking is the major cause of morbidity and mortality in the Western world. A further concern is that the incidence seems to be rising especially in young women. It is estimated that cigarettes kill around 350 people a day in Britain.
The development of smoking cessation services was identified as a priority for health authorities (HAs) in the Health Service Circular New NHS Smoking Cessation Services (HSC 1999/087), which also stated that up to £60m would be available over the subsequent 3 years to help HAs develop the services.
The National Service Framework for Coronary Heart Disease1 states that 'HAs, with PCGs/PCTs, will be expected to establish smoking cessation services for smokers who wish to quit', as part of its strategy for reducing heart disease in the population. The services should be available in a variety of settings and will provide support, advice and follow-up to individuals or groups.
Longton, where our practice is based, has a high incidence of chronic obstructive airways disease, and young teenagers who smoke. Our practice is in a health action zone, and we had been promised additional funding specifically for smoking cessation initiatives through our PCG, who appointed a smoking cessation facilitator to promote the initiative, and help oversee projects.
We therefore decided to take a pro-active approach to smoking cessation. A protocol was developed, using local guidelines, that would help us identify high-risk patients on our list who smoked and offer them appropriate advice and interventions to help them stop smoking for good.
We introduced the service to our patients in July 2000.
The process of stopping smoking can be broken down into three broad stages (adapted from the Prochaska and Di Clemente model,2 see later):
- Thinking about stopping and preparing to stop
- Stopping for good.
In our practice, all patients who express the desire to stop smoking are given a questionnaire (see below) which serves as both a working tool, by providing a proforma for staff to work through at each consultation, and a record for staff.
MY PLAN TO STOP SMOKING
Why, what and how?
When you prepare to stop smoking, it may be a positive step to think about the following questions and answer them:
- Why do I want to stop?
- What is the benefit to me?
- What date should I stop?
- How will I cope when I want a cigarette?
- What will I do to stop the craving?
- How will I spend the money that I save?
- How will my life improve?
- What will my family think?
The questionnaire helps to reinforce the advice given at the initial assessment, and ensures that the patient is actively involved in drawing up his/her own treatment plan to stop smoking.
At the same time, the patient is given a leaflet setting out an action plan with practical suggestions to encourage him/her to stop smoking:
ACTION PLAN FOR SUCCESS
- Get rid of ashtrays and clean the home
- Save the money for something special: set targets
- Get support from family and friends
- Keep busy and plan activities
- Have some low-calorie snacks ready, or chew sugar-free gum
- Take one day at a time
- Keep a diary of achievements
As with any new project in general practice, time is the main stumbling block. It takes time and commitment from all staff to ensure that the project is followed through.
A practice nurse has been given dedicated time to oversee the project, and a GP appointed to agree protocols and standard practice.
Recording of data can be a problem if all staff do not use the same Read codes when putting the information onto the computer register, or indexing the information if no computer is available. However, this is not a problem for us because the practice is fully computerised and we all use the same Read codes to input data.
- Try to establish how motivated the patient is to stop smoking, and give him/her as much help as necessary to achieve this.
- Encourage self-help and commitment, and enlist the help of family and friends, as the patient deems necessary.
- Give the patient helpline numbers and any appropriate leaflets that are available at the time.
Assessment and recording
- All new patients to be asked their smoking status, and all existing patients to be asked opportunistically (i.e. during routine consultations).
- The following information to be recorded on Lloyd George cards and the computer, using Read codes:
- What do you smoke?
- How much do you smoke?
- For how long have you smoked?
- When did you stop?
- Do you live with someone who smokes?
- Previous attempts at cessation:
- Have you tried to stop smoking before?
- Advice on stopping smoking to be given to all patients who smoke and have one or more of the following conditions:
- Chronic obstructive airways disease
- Coronary heart disease
- Cerebrovascular accident
- Women who are pregnant or planning to become pregnant.
- GP or practice nurse(s) to conduct an initial assessment, using the Prochaska and Di Clemente model,2 and to select an appropriate intervention based on the assessment,* and discuss this with the patient.
Counselling for motivational support is of the utmost importance and should be readily available initially and be encouraged along the way.
Follow-up sessions are booked before the patient leaves the surgery after the initial appointment. We recommend intensive support comprising weekly counselling sessions for a month and regular contact thereafter.
Nicotine replacement therapy
We are able to offer nicotine replacement therapy (NRT), which should be available on NHS prescription by 2001. However, one week's supply of NRT is currently being offered free locally to eligible persons by some pharmacies (the pharmacy quit scheme), or to those referred through quit centres (health centres or GP premises).
Bupropion tablets are indicated as an aid to smoking cessation in combination with motivational support in nicotine-dependent patients. This agent is prescribed, if the patient wants it. The dose is one 150mg tablet daily for 3 days, then one twice daily for a month.
It is recommended that patients start bupropion while they are still smoking, and set a 'quit' day within the first 2 weeks, since it takes around 7 days to achieve adequate blood levels. Treatment is a 79 week course.
In motivated patients, it makes good sense to use a treatment with positive features: bupropion has a 30% response rate, compared with 15% using NRT, and only 2% with counselling alone.
Progress so far is encouraging: we have a 40% quit rate at present, with only three patients lost to follow-up.
We are currently preparing an audit to see how the project can be improved, and plan to carry out the audit every 6 months.
* The Prochaska and Di Clemente model recognises five stages of change that a person undergoes in establishing new behaviour: precontemplation; comtemplation; preparation; action; and maintenance. A patient sould only be offered NRT or bupropion, for example, if he/she were in the 'action' (or 'stopping') stage.
- Department of Health. National Service Framework for Coronary Heart Disease. London: The Stationery Office, March 2000.
- Prochaska JO, Di Clemente CC. Towards a comprehensive model of change. In: Miller WR, Heather N (Eds). Treating Addictive Behaviours. New York: Plenum, 1986.
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