Jane Wright explains how healthcare professionals should use every opportunity to give advice to smokers and enable access to NHS stop smoking services
  • Helping smokers to stop smoking is often the most effective and cost effective of all the interventions they receive
  • There is significant untapped potential in primary care to enable smokers to access the most effective method of stopping smoking—NHS stop smoking services
  • All smokers should be advised to stop smoking and offered evidence-based support, even if they have not expressed a desire to stop
  • All primary healthcare professionals should use the Ask, Advise, Act model for provision of very brief advice on smoking
  • To ensure maximum effectiveness where there is no in-house service, refer the local stop smoking service to the smoker
  • Commissioners should include the delivery and recording of brief advice on smoking in all contracts.

Although NHS stop smoking services have helped over 2.5 million people to stop smoking in the short term and 625,000 people in the long term, saving over 70,000 lives,1 over 8 million people in England are still smokers.2 As 15.5% of all smokers in 2011 chose the least effective method of stopping smoking (unassisted),3 there is still significant potential for the systematic referral of smokers from primary care to enable them to access the most effective method of quitting—using an NHS Stop Smoking Service.

Very brief advice

Guidance from the Department of Health has identified that the systematic delivery of very brief advice (VBA) and referral of smokers to effective, evidence-based stop smoking services are a vital part of ensuring that these individuals access the most effective method of stopping smoking.1,3

NICE Public Health Guidance 1 recommends giving advice on quitting to every smoker.4 Very brief advice on smoking should be based on the Ask, Advise, Act (AAA) model (see Box 1). 5

There have been some positive changes to the quality and outcomes framework (QOF) for 2012/13 in the update to the indicators relating to smoking, (see Table 1) which put more emphasis on delivering VBA and offering support and treatment; this should help increase the number of referrals to NHS stop smoking services (see Table 1). 6

As GPs have frequent contact with smokers, they are in a key position to promote smoking cessation; however, despite 60% of smokers seeing their GP at least once a year, there is wide variation with regard to the delivery of VBA on smoking during consultations (see Figure 1). 7

Box 1: Very brief advice on smoking—30 seconds to save a life5

ASK and record smoking status—is the patient a smoker, ex-smoker, or non-smoker?

ADVISE on the best way of quitting—the best way of stopping smoking is with a combination of medication and specialist support

ACT on patient response—build confidence, give information, refer, and prescribe. Patients are up to four times more likely to quit successfully with NHS support

How to refer to a stop smoking service

  • ‘Call this number and they will put you in touch with someone who can arrange treatment and support you to stop’ or
  • ‘I can refer you to the stop smoking service and they will phone you to go through the options for treatment and support’ or
  • ‘When you are ready to stop, make an appointment at reception with our stop smoking advisor.’*
  • *(In practices, where there is an in-house service).
Table 1: Smoking-related QOF indicators 2012/136
No. Indicator Points Payment stages
ASTHMA 10 The percentage of patients with asthma between the ages of 14 and 19 years in whom there is a record of smoking status in the preceding 15 months 6 45–80%
SMOKING 5 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 15 months 25 50–90%
SMOKING 6 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 who smoke whose notes contain a record of an offer of support and treatment within the preceding 15 months 25 50–90%
SMOKING 7 The percentage of patients aged 15 years and over whose notes record smoking status in the preceding 27 months 11 50–90%
SMOKING 8 The percentage of patients aged 15 years and over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months 12 40–90%
Information 5 The practice supports smokers in stopping smoking by a strategy, which includes providing literature and offering appropriate therapy 2
  • CHD=coronary heart disease; PAD=peripheral arterial disease; TIA=transient ischaemic attack; COPD=chronic obstructive pulmonary disease; CKD=chronic kidney disease
Figure 1: GP advice to stop smoking7
GP advice to stop smoking
  • n=7611
  • Reproduced with kind permission from Key findings from the smoking toolkit study. Available at: www.smokinginengland.info

Rationale for delivering very brief advice

Giving patients advice and support to stop smoking is the single most cost-effective way to help smokers. Healthcare professionals will see many conditions caused or exacerbated by smoking, and smoking cessation will often be the most clinically and cost effective of interventions for individuals who smoke.8

Smokers expect to be asked about smoking by healthcare professionals as it demonstrates concern for their health—if healthcare professionals do not ask about smoking, the smoker may believe that it is not that important and can use this as a reason not to take action about their smoking. Therefore, healthcare professionals have a duty of care to raise this issue. Smokers usually take several attempts to quit smoking successfully, so it is important to keep giving advice at every opportunity and ensure that the smoker knows there are always other options available to help them stop successfully. This also links to the concept of ‘making every contact count’, which recognises that millions of people come into contact with the NHS and healthcare providers every day, and that these contacts are an opportunity to maintain and, where possible, improve health and wellbeing whatever the healthcare professional’s specialty or purpose of the contact.9

Currently, brief advice is often not given for a number of reasons, including staff believing that they have insufficient time or not having enough confidence to raise smoking cessation due to a perceived lack of knowledge; however, VBA will take only 30 seconds to deliver and, if done appropriately, does not require detailed knowledge, as this will be provided by specialists at the NHS stop smoking service.5

Best practice for delivering very brief advice

Very brief advice should be delivered as in Box 1. It is really helpful to inform the patient about the support that they will receive from the NHS stop smoking service—this is a combination of stop smoking medication and regular appointments, often individually or sometimes in a group, with a stop smoking adviser.10 It is useful to stress that accessing a service does not mean that the individual is committing themselves to a quit date straight away (if they are not quite ready), but that they can go along to find out what their options are.

Healthcare professionals should know about the available evidence-based stop smoking medications (varenicline, bupropion, and nicotine replacement therapy),11,12 available for patients in case patients ask about these interventions. Currently, there is a high level of interest in electronic cigarettes, which are currently not licensed for NHS use (the Medicines and Healthcare products Regulatory Agency is due to report on electronic cigarettes in Spring 2013).

At practices with no in-house stop smoking service, it is preferable to give the NHS stop smoking services a referral (fax, email, or post) rather than expect the smoker to contact the service themselves. This means that the service can then encourage, help, and advise the patient in more depth than is possible in primary care; this is important in maximising the potential for smokers to access services and going on to set a quit date and subsequently stop.

A short training module with more information on how to deliver VBA on smoking can be accessed at: www.ncsct.co.uk/vba. 13 It includes key facts, examples of delivery via film clips, links to supplementary information, and a short multiple-choice assessment.

Opportunities to deliver very brief advice

NHS Health Check

The NHS Health Check is a preventive programme for people in England aged 40–74 years that is aimed at preventing heart disease, stroke, diabetes, and kidney disease.14 Smoking is a key risk factor for vascular disease and is recorded as part of the standard assessment in the Health Check. All smokers should be offered a referral to an NHS stop smoking service. As 15 million people are eligible for an NHS Health Check,3 this programme would enable access to around 3 million smokers.

The Health Check can be delivered in a range of primary care settings, including GP practices, pharmacies, and community centres, which means that people who are not in regular contact with a GP surgery can be assessed elsewhere, thereby helping to tackle health inequalities.

Pharmacy settings

Pharmacies are an ideal location for very brief opportunistic advice as 84% of adults visit a pharmacy at least once a year,1 which amounts to 1.2 million health-related visits per day.1 In addition to potentially providing NHS Health Checks in pharmacies, other opportunities to promote smoking cessation within this setting include when patients present with certain prescriptions (e.g. for heart disease) and within other healthcare services that are delivered (e.g. medicines use reviews).

Dental settings

Nearly 60% of the adult population visit a dentist for regular check ups, including a high proportion of young people and pregnant women.1 There is plenty of scope to deliver systematic VBA in this setting, for example, via the updating of patient medical histories.

Optometry settings

There is a strong association between smoking and age-related macular degeneration for which there is currently no effective treatment1—optometrists have an opportunity to deliver very brief advice and refer people on to NHS stop smoking services.

Commissioning

Commissioners should support the systematic delivery of brief advice on smoking cessation, by including a requirement for recording and monitoring this process in all contracts. This can help to ensure that providers review or develop systems to implement and record brief advice as otherwise it may only be delivered by a few interested staff in an organisation.

Forthcoming guidance

It is worth noting that there is further guidance in development on smoking cessation. This includes the NICE public health guidance on Tobacco: harm-reduction approaches to smoking, which is due to be published in May 2013 (see Box 2).15 The recommendations in this guidance are intended to support and extend the reach and impact of existing stop smoking services, recognising that some people, particularly those who are highly dependent on smoking, may not be able (or do not want) to quit smoking in one step, or that they may not want to quit at all, and therefore harm reduction approaches provide an alternative. This new approach will mean that there will be a support option available for all smokers to enable them to make a positive change in their smoking, whether they want to quit or not. Some people who go onto a harm minimisation regimen will eventually go on to quit, but for those who do not, the health risks will still be lowered by this intervention.

NICE is also developing a quality standard on Smoking cessation: supporting people to stop smoking, for release in August 2013.16 This will provide a brief summary of best practice to drive and measure quality improvements in referral to, and delivery of, NHS smoking cessation services. The standard will build on previous guidance, best practice, and policy documents; and will provide another opportunity to promote and develop effective and very brief advice on smoking cessation.

Box 2: Summary of guidance on smoking cessation

Department of Health:

NICE:

In development:

National Centre for Smoking Cessation and Training:

Conclusion

There is still huge potential for primary care to contribute to the reduction of the number of smokers, and hence the significant burden of smoking-related disease. Systematic delivery of VBA as outlined here is not time-consuming and, in fact, can take less time than staff might currently be spending on giving smoking cessation advice. It is worth completing the National Centre for Smoking Cessation Training e-learning module on VBA13 to ensure effective interventions are provided. Commissioners can support an increase in provision of VBA by incorporating requirements to deliver and record them within all contracts.

  • Very brief advice given opportunistically in primary care is a highly cost-effective intervention
  • Commissioners and individuals in public health should look at smoking rates as recorded through QOF records to identify practices where extra intervention may be required
  • CCG leads could work with members of public health in local authorities (from 1 April 2013) and the NHS Commissioning Board to define local enhanced services to support smoking cessation (if these do not already exist), and offer these to Any Qualified Provider or to local practices to support referral to other services
  • Targeting of smoking cessation interventions to deprived populations is an effective method of addressing heath inequalities, and should be considered for inclusion in the Local Health and Wellbeing Strategy
  • CCGs should agree local formularies for smoking cessation products with all providers of smoking cessation services, and include in contract specifications.

QOF=quality and outcomes framework; CCG=clinical commissioning groups

  1. Department of Health. Local stop smoking services: service delivery and monitoring guidance 2011/12. London: DH, 2011. Available at: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_125939.pdf
  2. HM Government. Department of Health. Healthy lives, healthy people: a tobacco control plan for England. London: DH, 2011. Available at: www.ncsct.co.uk/usr/pub/DH-control-plan.pdf
  3. Department of Health. Local stop smoking services: key updates to the 2011/12 service and monitoring guidance for 2012/13. London: DH, 2012. Available at: www.wp.dh.gov.uk/publications/files/2012/09/9193-TSO-2900254-NHS-Stop-Smoking_Accessible.pdf
  4. National Institute for Health and Care Excellence. Brief interventions and referrals for smoking cessation in primary care and other settings. Public Health Guidance 1. London: NICE, 2006. Available at: www.nice.org.uk/guidance/PH1
  5. Nursing Practice Innovation Smoking Cessation. Very brief advice on smoking. Nursing Times 2012; 108 (9): 23.
  6. British Medical Association, NHS Employers. Quality and outcomes framework 2012/13. London: BMA, NHS Employers, 2012. Available at: www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/QOF/Pages/QualityOutcomesFramework.aspx
  7. Smoking in England website. Key findings from the Smoking Toolkit Study. www.smokinginengland.info (accessed 9 January 2013).
  8. Fu S, Partin M, Snyder A et al. Promoting repeat tobacco dependence treatment: are relapsed smokers interested? Am J Managed Care 2006; 12: 235–243.
  9. NHS Future Forum. The NHS’s role in the public’s health: a report from the NHS Future Forum. London: Department of Health, 2012. Available at: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_132114.pdf
  10. SmokeFree website. Free local NHS stop smoking service. Available at: smokefree.nhs.uk/ways-to-quit/local-nhs-stop-smoking-service/
  11. National Institute for Health and Care Excellence. Smoking cessation services. Public Health Guidance 10. London: NICE, 2008. Available at: www.nice.org.uk/guidance/PH10 nhs_accreditation
  12. National Institute for Health and Care Excellence. Varenicline for smoking cessation. Technology Appraisal 123. London: NICE, 2007. Available at: www.nice.org.uk/guidance/TA123 nhs_accreditation
  13. National Centre for Smoking Cessation and Training website. Very brief advice training module. Available at: www.ncsct.co.uk/vba (accessed 18 December 2012).
  14. NHS Choices website. What is NHS Health Check? www.nhs.uk/Planners/NHSHealthCheck/Pages/NHSHealthCheckwhat.aspx
  15. National Institute for Health and Care Excellence. Tobacco: harm-reduction approaches to smoking. Draft guidance. London: NICE, 2012. Available at: www.nice.org.uk/guidance/PHG/52
  16. National Institute for Health and Care Excellence website. Smoking cessation: supporting people to stop smoking. www.nice.org.uk/guidance/QSD/47 (accessed 10 January 2013). G