Jane Wright shares 10 key points on how to support patients in their efforts to quit smoking
Read this article to learn more about:
- the likely benefits smoking cessation can have on patients and the practice as a whole
- how best to raise the issue of smoking cessation with patients
- pharmacological and non-pharmacological approaches to helping patients to stop smoking.
Smoking is the leading cause of preventable death in Great Britain1 and is one of the most significant factors impacting on health inequalities and ill health; especially cancer, coronary heart disease, and respiratory disease.2 Approximately one-half of persistent smokers will die as a result of their habit and on average, cigarette smokers die about 10 years younger than non-smokers.3 Helping smokers to quit brings huge benefits to a range of people and services, particularly general practice.
1 Prioritise smokers
Treating smoking-related illness is estimated to cost the NHS £2.7 billion a year with the wider economic costs reaching over £13 billion a year (taking into account lost productivity, the cost of cleaning up tobacco litter, and the cost of smoking-related house fires).4,5 Reducing the prevalence of smoking therefore remains a key priority for national and local public health services.6 Smoking cessation is an effective life-saving intervention; a combination of pharmacological and behavioural support is the most effective approach—patients receiving specialist NHS support are over three times more likely to quit compared with people who try to quit unaided.7
Practitioners should be aware of the positive outcomes that can be achieved in general practice from targeted smoking cessation and the impact this can have on their practice, which includes a reduction in the number of smokers, appointments, home visits, and unplanned emergency admissions.
2 Raise the issue
It is really important to raise the issue of smoking. If you do not ask a smoker about their tobacco use it can send negative messages that 'you don't care if the patient smokes', that 'you don't have an effective intervention to offer', and 'you don't think the smoker is capable of quitting'. Any of these messages can undermine a patient's chance to quit smoking.8
Healthcare professionals working in primary care have daily contact with a significant number of smokers, and most smokers see their GP at least once a year. This is an ideal opportunity to really make a difference.7
Systems that can be used to drive referrals of smokers into evidence-based stop smoking services include:
- NHS Health Checks—a national risk assessment and prevention programme for people aged between 40 and 74 years to identify early signs of heart disease, stroke, kidney disease, type 2 diabetes, and certain types of dementia. Following assessment, anyone identified as being 'at risk' should receive advice on achieving and maintaining a healthy lifestyle, including advice about stopping smoking, and be referred to stop smoking support where relevant9
- Quality and Outcomes Framework (QOF)—the annual reward and incentive programme for GP practices in England—includes indicators relating to smoking (see Table 1, below).10
|SMOK002. The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the preceding 12 months||25||50–90%|
|SMOK003. The contractor supports patients who smoke in stopping smoking by a strategy which includes providing literature and offering appropriate therapy||2|
|SMOK004. The percentage of patients aged 15 or over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 24 months||12||40–90%|
|CHD=coronary heart disease; PAD=peripheral arterial disease; TIA=transient ischaemic attack; COPD=chronic obstructive pulmonary disease; CKD=chronic kidney disease;|
|Adapted from: NHS Employers. 2016/17 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF)—guidance for GMS contract 2016/17. NHS Employers, 2016. Available at: www.nhsemployers.org/your-workforce/primary-care-contacts/general-medical-services/quality-and-outcomes-framework|
3 Provide very brief advice
Some practices are very proactive regarding smoking cessation; however, the Smoking Toolkit Study indicates that the delivery of effective, very brief advice (VBA) is not currently systematic or standardised. Figure 1, below, indicates that a large proportion of smokers either receive ineffective interventions from their GP or none at all.7
For VBA to be effective it needs to include an offer of support, not just advice. Smokers who are offered support by their GP, rather than only advice to stop, are almost twice as likely to make a quit attempt.7 One study has shown that the frequency of quit attempts increases by 68% and 117% when a GP offers nicotine replacement therapy or behavioural support, respectively. 11
All healthcare professionals should provide VBA on stopping smoking (Ask, Advise, Act; see Figure 2, below) and routinely refer smokers to local stop smoking service providers. Training on the delivery of VBA is available as a short e-learning module and may be available from your local stop smoking service.
4 Change your language
Simple changes to how you talk to patients who smoke can really make a difference in supporting them to move towards a quit attempt. Instead of asking if they want to stop smoking now, ask, 'Do you see yourself as a life-long smoker?' Most smokers don't see themselves smoking for the rest of their life. A useful follow-up question would be, 'Is there any particular reason you are waiting before you quit?'—for some patients this means they will bring their quit date forward as they wonder what they have been waiting for.
Where possible, link smoking to the condition that the patient is presenting with as this will provide a 'teachable moment'. Patients are likely to be more susceptible to advice in these situations, with their health at the forefront of their mind.13Visit Ash.org for more information on the links between smoking and a range of disease areas.
5 Refer to an NHS stop smoking service
Healthcare professionals have a duty of care to offer the most effective stop smoking support available, and to offer potentially life-saving treatment without delay. In the case of smoking cessation, this support is likely to come in the form of an NHS stop smoking service, which your practice may provide inhouse with staff trained as Stop Smoking Advisors, your local service may deliver at your practice for you, or you may refer patients out to another venue. Whichever method of service delivery you have at your disposal, it is vital that the referral process is quick and easy.
6 Offer pharmacological support
As stated in NICE Public Health Guideline 10 (PH10) on Stop smoking services, smokers should be given the best chance of success for any given quit attempt with the use of licensed pharmacotherapy—namely, nicotine replacement therapy (NRT), varenicline, or bupropion—alongside intensive behavioural support.14 When deciding which therapies may be used, practitioners should discuss the options with the patient, considering:14
- whether a first offer of referral to the NHS stop smoking service has been made
- contraindications and the potential for adverse effects
- the patient's personal preferences
- the availability of appropriate counselling or support
- the likelihood of the patient following the course of treatment
- the patient's previous experience of smoking cessation aids.
NICE Public Health Guideline 48 (PH48) on Smoking: acute, maternity and mental health services also includes the caveat that varenicline and bupropion should not be offered to pregnant or breastfeeding women, or people under the age of 18, and may be used with caution in people with mental health problems (healthcare professionals are advised to refer to the relevant summaries of product characteristics for more information).15
7 Support the use of e-cigarettes
E-cigarettes are the most common aid that smokers use to help them quit.16 E-cigarettes deliver nicotine through a vapour rather than smoke. They heat and vaporise a solution that typically contains nicotine, propylene glycol or vegetable glycerine, and flavourings. E-cigarettes do not burn tobacco and do not produce tar or carbon monoxide, and although the vapour has been found to contain some toxicants also found in cigarette smoke, these are at much lower levels. E-cigarettes are not completely risk free; however, based on the current evidence, they carry a fraction of the risk of smoking (it is estimated that use of e-cigarettes may be 95% less harmful than smoking).17
Currently there are no e-cigarettes available that are licensed as medicines, so they are not available on the NHS; however, evidence shows that they can be effective for quitting.18
In practice, smokers who have tried other methods of quitting could be encouraged to try e-cigarettes and those smokers not ready to quit could be encouraged to switch to e-cigarettes as a harm reduction strategy.
8 Coordinate best practice
To be as effective as possible, all staff in the practice will have a role to play—just relying on one or two people who are trained in smoking cessation will not provide the best outcomes. As recommended across NICE PH1 on Smoking: brief interventions and referrals and NICE PH10 on Stop smoking services, advising patients to quit and referral to an intensive support service are actions that should be implemented by:14,19
- nurses in primary and community care
- hospital clinicians
- community workers.
Further to this, NICE recommends that all healthcare professionals in primary care should receive training on the delivery of VBA,14 monitoring systems should be set up to ensure health professionals have access to information on the current smoking status of their patients,19 and performance data should be audited routinely.14
9 Keep at it!
Tobacco smoking is a chronic relapsing condition;20 therefore, most smokers will make several attempts to quit before they do so for good. Any period of quitting should be seen as a success, as it is a step towards quitting for good, and relapses should be seen as temporary disease flareups requiring further treatment.8 So, it is important to keep raising the issue and keep supporting the patient to quit in order to give them a much greater chance of quitting.
10 Raise the issue across all primary care settings
Community pharmacies see over 1.6 million people per day, and are often people's first point of contact with health services.21 They are a valuable setting for referring and/or supporting smokers to quit. In addition to offering health promotional material, pharmacists should ask customers, 'Does anyone in your household smoke?' to identify smokers.
Over 60% of the adult population in England visits a dentist for regular check-ups.22 Many people are not aware of the effects of smoking on the mouth so it is important to highlight these to smokers. As well as its general health benefits, stopping smoking has also been associated with improved dental outcomes.23 Ask about smoking as part of the patient's medical history, and ask again regularly, outlining the links between smoking and oral health. For more information, the NCSCT has developed a fact sheet.
Public awareness of the effects of smoking on the eyes is low, yet the prospect of going blind (for example, from age-related macular degeneration) can be a strong motivator to quit.24 Ask about smoking as part of the medical history, and ask again regularly, outlining the links between smoking and eye health.
- Office for National Statistics. Adult smoking habits in Great Britain: 2014. ONS, 2016. Available at: www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2014
- Action on Smoking and Health. Smoking statistics—illness and death. ASH, 2016. Available at: ash.org.uk/files/documents/ASH_107.pdf
- Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ, 2004; 328: 1519–1527.
- Callum C, Boyle S, Sandford A. Estimating the cost of smoking to the NHS in England and the impact of declining prevalence. Health Econ Policy Law 2011; 6: 489–508.
- Featherstone H, Nash R. Cough up: balancing tobacco income and costs in society. Policy Exchange—Research note, 2010. Available at: policyexchange.org.uk/publication/cough-up-balancing-tobacco-income-and-costs-in-society/
- Department of Health. Improving outcomes and supporting transparency—part 1A: A public health outcomes framework for England, 2013–2016. DoH, 2013. Available at: www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency
- West R, Brown J. Smoking and smoking cessation in England 2011: Findings from the smoking toolkit study. London, 2012. Available at: www.smokinginengland.info/sts-documents/ (accessed 7 December 2016).
- Rennard S, Daughton D. Smoking cessation. Clin Chest Med 2014; 35: 165–76.
- NHS Health Check website. www.nhs.uk/Conditions/nhs-health-check/Pages/NHS-Health-Check.aspx (accessed 6 December 2016).
- NHS Employers. 2016/17 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF)—guidance for GMS contract 2016/17. NHS Employers, 2016. Available at: www.nhsemployers.org/your-workforce/primary-care-contacts/general-medical-services/quality-and-outcomes-framework (accessed 7 December 2016).
- Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance. Addiction 2012; 107 (6): 1066–1073.
- National Centre for Smoking Cessation and Training. Local stop smoking services—service and delivery guidance 2014. NCSCT, 2014. Available at: www.ncsct.co.uk/publication_service_and_delivery_guidance_2014.php
- Flocke S, Antognoli E, Step M et al. A teachable moment communication process for smoking cessation talk: description of a group randomised clinician-focused intervention. BMC Health Services Research 2012; 12: 109–121.
- NICE. Stop smoking services. Public Health Guideline 10. NICE, 2008 (last updated 2013). Available at: www.nice.org.uk/ph10
- NICE. Smoking: acute, maternity and mental health services. Public Health Guideline 48. NICE, 2013. Available at: www.nice.org.uk/ph48
- West R, Beard E, Brown, J. Smoking toolkit study—Trends in electronic cigarette use in England. University College London, 2016. Available at: www.smokinginengland.info/sts-documents/ (accessed 7 December 2016).
- McNeill A, Brose L, Calder R, Hitchman S. E-cigarettes: an evidence update. Public Health England, 2015. Available at: www.gov.uk/government/publications/e-cigarettes-an-evidence-update
- McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev 2014: 12: CD010216
- NICE. Smoking: brief interventions and referrals. Public Health Guideline 1. NICE, 2006. Available at: www.nice.org.uk/ph1
- Tobacco Use and Dependence Guideline Panel. Treating tobacco use and dependence: 2008 Update. Rockville (MD): US Department of Health and Human Services, 2008. Available at: www.ncbi.nlm.nih.gov/books/NBK63952/
- Local Government Association. Community pharmacy—local government’s new public health role. LGA, 2013. Available at: www.local.gov.uk/publications/-/journal_content/56/10180/5597846/PUBLICATION
- The Health and Social Care Information Centre. Executive summary: adult dental health survey 2009. HSCIC, 2011. Available at: content.digital.nhs.uk/catalogue/PUB01086/adul-dent-heal-surv-summ-them-exec-2009-rep2.pdf
- National Centre for Smoking Cessation and Training. The clinical case for providing stop smoking support to dental patients. NCSCT, 2011. Available at: www.ncsct.co.uk/publication_supporting-dental-patients.php
- Action on smoking and health. Fact sheet—smoking and eye disease. ASH, 2014. Available at: ash.org.uk/category/information-and-resources/fact-sheets/G