Managing smoking cessation

Smoking remains the largest preventable cause of ill health in the United Kingdom, responsible for up to 120 000 deaths annually.¹ This week’s publication of smoking cessation guidelines, both in full² and in summary form (p 183)³, marks what the NHS can do to fight this epidemic and emphasises that primary healthcare teams are central to this effort. This makes sense: most smokers will be in contact with primary healthcare services throughout their lives, and the potential effect of primary care is large.⁴

Much could be done to improve the management of smoking cessation in primary care,⁵ so the guidelines are welcome, and most of their recommendations are sound. It is particularly important that smokers who are motivated to stop are instructed about the correct use of nicotine replacement therapy and offered supportive follow up.⁶ The guidelines should increase awareness about the efficacy of nicotine replacement, and if specialist smoking cessation clinics become available these could provide further help to motivated smokers. The suggestion (in the full guidelines) that primary healthcare teams should adopt a systematic approach towards ascertaining and documenting smoking status in medical records is also useful. When this information is available during consultations it results in more opportunistic discussions about smoking.⁷

The guidelines correctly emphasise that most time and resources should be spent on motivated smokers. After raising the issue of smoking clinicians should assess smokers’ motivation to stop and tailor any further discussion accordingly. Objective methods of assessing smokers’ motivation to stop are badly needed, and developing them should be a priority for research. Such measures could help clinicians to decide whether to invest time in encouraging individual smokers to stop or merely gather information about their habit.

The recommendations that general practitioners should always advise smokers to stop and should repeat this advice at every opportunity are questionable because they have never been adequately tested. Most trials of general practitioners’ antismoking advice have been short term.⁴ Although participating doctors have discussed smoking with all presenting smokers, this has usually only been for brief periods—less than a year in most studies. Most smokers will have been advised only once. When studies have involved doctors giving repeated advice, smokers have voluntarily reattended for this.⁸ Such motivated smokers differ from unselected ones consulting general practitioners and are more likely to stop smoking. We do not know whether this is because of their increased motivation or the repeated advice. Fewer than half of all smokers consider that their smoking is a problem,⁹ so repeated advice would be directed towards many smokers with little motivation to stop—and perhaps much resistance. Currently, patients rate general practitioners’ lifestyle advice highly.⁹ If general practitioners discussed smoking during every patient contact, would patients still value it and would it still be as effective?¹⁰

Implementing the guidelines will involve a massive change in clinical practice, as only about 30% of smokers who have seen their general practitioner in the previous year recall doctors’ antismoking advice.¹¹ Merely publishing the guidelines is not an effective method of implementation.¹² If they are to have any impact on routine clinical practice they must be implemented by using multifaceted, evidence based strategies that take into account prevailing obstacles to change.¹² Unfortunately, this issue is not addressed by the guidelines.

Local discussion of research evidence is important in getting research into practice.¹³ Primary care groups may be an ideal vehicle to promote local consensus about smoking cessation. They will be required to address national priorities such as coronary heart disease, cancer, and health inequalities¹⁴—all conditions to which smoking contributes. Primary care groups could adopt smoking cessation as a topic for clinical governance, using evidence based review criteria for audit and feedback.⁵ They might also stipulate that chronic disease management clinics (for asthma and diabetes) should include the evidence based management of smoking cessation. As the new structures for primary care develop, other methods for integrating antismoking interventions into routine clinical practice may become apparent. It is important to realise, however, that these guidelines are only the start of a process of improving the primary care management of smoking cessation.

Education and debate p 183