The Practitioner - 1868-2020: Supporting general practitioners for more than 150 years - GPs have key role in helping patients to stop smoking

GPs have key role in helping patients to stop smoking

23 May 2012

AUTHORS

Dr Jamie Brown PhD, Research Associate, Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, UCL, London, UK

Dr Tobias Raupach MD, Cardiologist and Research Associate, Department of Cardiology and Pneumology, University Hospital Göttingen, Göttingen, Germany

Professor Robert West PhD, Professor of Health Psychology and Director of Tobacco Studies, National Centre for Smoking Cessation and Training, London.

Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, UCL, London, UK

Article

Fifty years ago the Royal College of Physicians published its report Smoking and Health¹ that firmly established the impact of smoking on health in the public consciousness. This was the trigger for a sustained decline in smoking prevalence in the UK and a catalyst for many subsequent activities that have successfully reduced morbidity and mortality from smoking.²

However, 18% of all deaths in adults aged 35 or over in England are still attributable to smoking.³ Almost all these premature deaths could be avoided if smokers stopped before their mid-thirties but only a quarter of people who have ever smoked regularly manage to quit by this age.

The pivotal role of GPs in smoking cessation is reflected by the inclusion of smoking indicators in the QOF, see box 1. It has long been known that advice from the patient’s GP is one of the most important triggers to a smoker making an attempt to quit.^{4, 5} Recent research has shown that this can be done more easily, quicker and more effectively than previously thought.^{6, 7}

Smoking cessation advice

All patients attending a surgery for any reason who have smoked within the past three years should be offered advice on stopping smoking.

Studies have shown that many GPs prefer to limit advice to current smokers with smoking-related conditions,^{8, 9} and feel that quite a large proportion of consultations are inappropriate for raising the topic of smoking.¹⁰

However, the evidence is clear: smokers without smoking-related diseases are just as likely to respond to advice as those with them.¹¹

Every opportunity to raise the topic of smoking is a potential opportunity to save a patient’s life. Every day that a person aged 35 or older continues to smoke costs him or her six hours of life expectancy.¹²

It is also important to re-assess the status of former smokers who were recorded as having stopped within the past three years. They may well have relapsed. Half of those who stopped six months ago will relapse at some point as will 40% of those who stopped a year ago.¹³

New evidence points to a change in the way smoking advice should be given. Rather than going through a litany of advising smokers to stop, asking whether smokers are interested in stopping and only if they are interested offering support, a better approach is simply to offer help with stopping to all smokers.^{6, 7} This puts the interaction on a positive supportive footing with minimal risk of causing upset.¹⁴

Online training module

In response to this new evidence, the National Centre for Smoking Cessation and Training (NCSCT) has launched a new online training module on how GPs can best deliver smoking cessation support to their patients (www.ncsct.co.uk/vba).

The module is called Very Brief Advice and is designed to be used opportunistically in less than 30 seconds in almost any consultation with a smoker, see box 2.

Smoking cessation therapy

Smokers who attend stop smoking services should receive treatment for what is an addiction and not simply a lifestyle choice.^15-17 Smoking cigarettes leads to a rapid increase in nicotine concentration in the brain.¹⁸ Nicotine then acts on nicotinic cholinergic receptors to release dopamine and other neurotransmitters.^{19, 20} This action results in several mechanisms that sustain addiction. These include powerful urges to smoke in the presence of particular cues and a nicotine hunger – a drive to smoke when CNS nicotine levels become depleted.^21-24

Optimum treatment involves behavioural support plus one of the smoking cessation medications now available.^{25, 26} Behavioural support includes a number of specific behaviour change techniques that have been found to enhance the smoker’s chances of remaining abstinent.^{27, 28} These techniques include:

• measurement of carbon monoxide in expired air to bring home the risks of smoking and show the immediate benefit of stopping

• advice on best use of medication

• helping smokers to put in place a very clear ‘not a puff’ rule to counter the tendency to think they can ‘just have one’.

The three pharmacotherapies currently licensed and widely used in the UK are nicotine replacement therapy (NRT), varenicline and bupropion.

The most effective medication option is either varenicline or combination NRT (i.e. the patch and one of the faster acting products such as gum or an inhalator).^{26, 29, 30}

A large RCT has recently found that cytisine, a very low cost drug that acts in a similar way to varenicline, is effective but this is unlikely to be available on the NHS until the finding has been confirmed by further trial evidence.³¹

Although the popular press occasionally carries reports and opinion pieces arguing that treatment to aid smoking cessation is not effective in the real world³² there is a wealth of evidence to refute this.^{25, 26, 29, 30}

GP advice is one of the most important triggers to a smoker making an attempt to quit. This offers GPs the opportunity to play a critical role in reducing the huge number of premature deaths attributable to smoking. Evidence shows that offering help to all smokers is easier, quicker and likely to be more effective than just advising smokers to stop or asking whether they are interested in quitting.

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