Dr Tim Coleman explains how GPs can use a number of strategies to determine which patients are the most likely to benefit from interventions on smoking cessation
Smoking remains a massive public health problem in the UK—approximately 22% of the population are smokers1 and it is the cause of very high morbidity and mortality rates, with over 80,000 people dying from smoking-related causes each year.2 The scale of harm caused by smoking is such that primary care teams should be implementing a systematic, coordinated approach to managing it, as they do for other serious chronic diseases, like diabetes.
In 2006, NICE released its important public health guideline on Brief interventions and referral for smoking cessation in primary care and other settings.3 This article discusses those recommendations that are relevant to primary care teams, which, if effectively implemented, could result in substantial health gain for patients.
For some years the overall trend in smoking prevalence has declined,2,4 so it would be easy to become complacent about the need to combat the epidemic of exposure to tobacco smoke. Although prevalence rates have fallen considerably, smoking is still greater among those at the lower end of the socio-economic gradient. It accounts for half the difference in survival to 70 years of age between social class I (professional occupations) and class V (unskilled occupations).5,6 Consequently, much of the observed health inequality, which is related to economic disadvantage, can be attributed to smoking.5 Additionally, around 30% of pregnant women smoke for at least some time during pregnancy7 and 17% smoke throughout this period.8 Infants of women who smoke are more likely to become smokers themselves,9 and women who continue smoking throughout pregnancy are often less well educated and less financially advantaged than those who manage to stop.5,7 Smoking in pregnancy, therefore, helps to perpetuate smoking-related health inequalities, compounding the impact that smoking has on poorer communities.
The term ‘brief interventions’ is used to describe a series of simple approaches that GPs and other primary care healthcare professionals can use to help their patients to stop smoking. Typically, brief interventions last between 5 and 10 minutes, and they can all be delivered in primary care consultations.3 The NICE guidance states that brief interventions may include one or more of the following activities:3
- provide simple opportunistic advice to help smokers quit
- assess the patient’s commitment to stop smoking
- offer pharmacotherapy and/or behavioural support
- provide self-help material and refer to intensive support (e.g NHS stop-smoking services).
There is strong evidence that these brief interventions are effective for promoting smoking cessation. Simple, opportunistic advice regarding smoking, given by a GP, which makes clear to the recipient that smoking cessation is needed, has a small, but significant effect, resulting in an increase of 1–3% of smokers subsequently stopping.10 Adding pharmacotherapy (e.g. nicotine replacement therapy [NRT],11 bupropion,12 or varenicline13) almost doubles the chances of a motivated quitter being successful in any one quit attempt. Providing intensive behavioural support,14,15 such as that from an NHS stop-smoking service has a similar impact.16
The NICE guideline on brief interventions3 makes a series of recommendations for healthcare commissioners as well as healthcare providers, but not all of these are relevant within primary care. The recommendations that should be followed and that apply directly to primary care are summarised in Box 1.3
Recording smoking status
The NICE guideline outlines simple interventions, which should be relatively easy to implement for the vast majority of primary care healthcare teams. A priority to assist implementation is for practices to have a systematic, periodically repeated, method for ascertaining the smoking status of patients.3 Many practices will already have such a system in place to comply with the quality and outcomes framework, which was introduced as part of the 2004 GP contract.18,19
Information on smoking status can be collected by almost any member of the primary care healthcare team who is adequately trained to collect valid data. Once ascertained, smoking status should be entered into a prominent section of the patient’s medical records;20 all clinicians need to be aware of where these data are located, so that they can be referred to during consultations. Healthcare professionals are cautious about raising the subject of smoking,21 and having prior knowledge of smoking status can help them to decide whether or not to address this issue with individuals.
It is vital that doctors, nurses, and other clinicians in primary care act upon the information on smoking status in a patient’s medical records during consultations. Action might entail enquiring about smoking to replace out-of-date records of smoking status. Clinicians may also decide to advise smokers that stopping is very important for their health or to enquire whether or not they are interested in doing so.
All healthcare professionals should acquaint themselves with the local procedures for referring those smokers who want to stop to NHS stop-smoking services. Smokers who receive intensive behavioural support, which these services can provide, are much more likely than others to stop smoking permanently,16 so it is vital that clinicians use them. Most primary care teams do not have the resources to provide intensive behavioural support ‘in house’ but stop-smoking services can provide this therapy option. In addition, practice nurses and other primary care team clinicians can be trained to provide behavioural support, and may also work for local stop-smoking services, and in this instance, intensive support may be readily accessible at the GP’s practice.
Another important priority is for clinicians to be confident about prescribing pharmacotherapy for smoking cessation. Recommendations from NICE indicate that pharmacotherapy should be offered to smokers who are reluctant to attend NHS stop-smoking services. The brief interventions guidance encourages clinicians to consult Technology Appraisal 39 for further clarification on the prescription of NRT and bupropion.3,22 However, this document is now somewhat dated, being written before the advent of a new, effective therapy for smoking cessation—varenicline.13 For up-to-date recommendations on using the different pharmacotherapies, prescribers should refer to NICE Public Health Guidance 10: Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities.17
Although this guidance was produced for NHS stop-smoking services, the recommendations on pharmacotherapy can logically be applied in primary care. To support a smoking cessation attempt, NRT, bupropion, or varenicline can be prescribed, with the choice of drug being a matter of patient preference. Additionally, to help heavier smokers to quit, nicotine patches can be combined with shorter-acting forms of NRT (i.e. either gum, inhalator, lozenge, or nasal spray) to deliver more effective, higher doses of nicotine to substitute for the greater nicotine load that these smokers would have received from their tobacco.
As most primary care healthcare teams will already have systems in place to update, monitor, and record smoking status, these data can be used to audit their provision of advice and other treatments for smoking cessation. The greatest challenge for primary care healthcare teams is likely to be finding time to deliver brief interventions. The NICE guidance recommends that GPs use every opportunity to carry out brief interventions to advise smokers to stop; however, adding just 2 minutes (i.e. the most minimal of brief interventions) to every patient’s consultation in a 15-patient surgery session would extend a doctor’s consulting period by 30 minutes. Many GPs will find this level of activity difficult to sustain, even for an important topic like smoking, and most clinicians will need to determine for which patients smoking cessation is a priority.
There are divergent opinions on the value of addressing smoking with different patients, but most GPs will consider it worthwhile spending time on the issue with patients who are motivated to try stopping, or who have smoking-related symptoms.23 The NICE guidance is helpfully pragmatic on this point, acknowledging that time is best spent with those who are motivated to try quitting, and permits the issue to be ‘dropped’ for a whole year when smokers state that they are not ready to try quitting. For patients who are not yet ready to stop, the GP is advised to continue with opportunistic brief interventions, and medical records of smoking status should be updated annually. As only around 20% of smokers who attend a GP consultation intend stopping in the near future,24 it is unlikely that in any one surgery session GPs will encounter many smokers who will want to quit. This means that healthcare professionals who acquaint themselves with the NICE brief interventions guidance can put it into effect without this adding, unsustainably, to their workload.
To have the biggest impact at an individual level, healthcare professionals should probably aim to deliver a brief intervention that is suited to the level of motivation displayed by the smoker. The most time and energy should be spent encouraging behaviour change in those smokers who are most likely to respond.
- Smoking cessation remains a key performance indicator for PCTs
- Simple brief interventions in primary care by healthcare professionals (e.g. GP, midwife, health visitor, pharmacist, practice nurse) are cost effective
- Those smokers committed to stopping can benefit from additional pharmacotherapy (NRT, bupropion or varenicline)
- Dedicated intensive behavioural support also helps quit rates and should be commissioned locally
- Non-clinicians (e.g. community workers, teachers) can also deliver smoking cessation programmes
- Practice-based commissioning groups should consider a local smoking cessation strategy to ensure effective support is offered in all healthcare settings and targeted at hard-to-reach groups
- Costs of pharmacotherapy:
- varenicline c. £163a for a 12-week course
- NRT c. £140 for three-month courseb
- bupropion c. £80 for 8-week courseb
- Goddard E. Smoking and drinking among adults, 2006: general household survey. London: Office of National Statistics, 2008.
- The Information Centre. Statistics on Smoking, England 2007. The Information Centre for Health and Social Care, 2007.
- 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.
- Jarvis M. Monitoring cigarette smoking prevalence in Britain in a timely fashion. Addiction 2003; 98 (11): 1569–1574.
- Acheson D. Independent inquiry into inequalities in health. London: The Stationery Office; 1998.
- Wanless D, HM Treasury. Securing good health for the whole population: final report — February 2004. London: DH, 2004.
- Owen L, Penn G. Smoking and pregnancy: A survey of knowledge, attitudes and behaviour, 1992–1999. London: Health Education Authority, 1999.
- Bolling K. Infant Feeding Survey 2005: Early Results. The Information Centre for Health and Social Care, 2006.
- Batstra L, Hadders-Algra M, Neeleman J. Effect of antenatal exposure to maternal smoking on behavioural problems and academic achievement in childhood: prospective evidence from a Dutch birth cohort. Early Human Development 2003; 75: 21–33.
- Stead L, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008; (2): CD000165.
- Silagy C, Lancaster T, Stead L et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2004; (3): CD000146.
- Hughes J, Stead L, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2007; (1): CD000031.
- Cahill K, Stead L, Lancaster T. Nicotine receptor partial agonists for smoking cessation Cochrane Database Syst Rev 2008; (3): CD006103.
- Lancaster T, Stead L. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev 2005; (2): CD001292.
- Stead L, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database Syst Rev 2000; (2): CD001007.
- Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one-year outcomes. Addiction 2005; 100 (2): 59–69.
- National Institute for Health and Care Excellence. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant and hard to reach communities. Public Health Guidance 10. London: NICE, 2008.
- Department of Health. Investing in general practice: the new general medical services contract. London: DH, 2003.
- Campbell S, Reeves D, Kontopantelis E et al. Quality of primary care in England with the introduction of pay for performance. N Engl J Med 2007; 357 (2): 181–190.
- Fiore M, Hatsukami D, Baker T. Effective tobacco dependence treatment. JAMA 2002; 288 (14): 1768–1771.
- Coleman T, Murphy E, Cheater F. Factors influencing discussions about smoking between general practitioners and patients who smoke: a qualitative study. Br J Gen Pract 2000; 50 (452): 207–210.
- National Institute for Clinical Excellence. Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation. Technology Appraisal Guidance No. 39. London: NICE, 2002.
- Coleman T, Cheater F, Murphy E. Qualitative study investigating the process of giving anti-smoking advice in general practice. Patient Educ Couns 2004; 52 (2): 159–163.
- Coleman T, Wynn A, Barrett S et al. Intervention study to evaluate pilot health promotion payment aimed at increasing general practitioners’ antismoking advice to smokers. BMJ 2001; 323 (7310): 435–436.G