A time to quit: supporting smoking cessation in general practice

A new report exploring GPs’ prescribing practices for quitting services and treatment, published by the British Lung Foundation, revealed a 75% decline in the number of ‘stop smoking’ aids dispensed in 2016-17 compared with 2005-6 and reflected on the impact this is likely to have on patients and healthcare provisions in the long-term.

Practice Business takes a closer look at what GP practices can do to push forward in the fight against smoking and to support cessation.

According to figures from the Office for National Statistics, smoking is still the leading cause of preventable death in Great Britain; it increases the risk of cancer, respiratory diseases and is linked to cardiovascular disease and diabetes, to list but a few of the negative impacts on health that smoking has.

“People who smoke are likely to be high users of NHS services,” Alison Cook, director of policy for the British Lung Foundation (BLF), said following the publication of research that revealed a decline in the number of smoking aids being dispensed in England, Scotland and Wales in 2016/17 compared with 2005/6. “Decommissioning the prescribing of stop smoking aids will only achieve short-term savings,” she cautioned, adding that this decline will result in a greater burden on the NHS in the long-term – in terms of hospital admissions and the impact on already stretched A&E services.

Smoking cessation has multiple benefits for both patients and the healthcare providers they rely on – such as general practice. Better patient health will, in the long-term, reduce pressure on the provider plus the cost to the NHS of treating smoking-related illness is an estimated £2.5 bn a year (Statistics on Smoking) and the wider cost to society is around £12.7bn a year (The local costs of smoking in England – 2017 Action on Smoking and Health).

NICE guidance clearly outlines the importance of stop smoking interventions and services so what should practices be considering?

The role of healthcare providers

NICE guidelines detail recommendations for commissioners and managers of ‘stop smoking services’ – general practices will fall squarely in the latter. Practices are an access point for the advice and assistance which can help smokers quit so ensuring that information is available within your practice – posters, NHS leaflets, etc. – as well as on your practice website and from your practice staff is essential.

Health professionals – such as practice nurses, clinical pharmacists and GPs – play an important role in educating and motivating smokers to stop, as well as assessing their nicotine dependence and providing the assistance a patient needs to quit.

Know who your smokers are

It is important that health professionals identify smokers, assess their smoking status and offer them advice and cessation treatment at every opportunity – especially when a patient presents with a health condition that is caused or exacerbated by smoking.

There is a range of evidence-based strategies available to support effective smoking cessation interventions in general practice; where there’s an active system in place smokers can more easily be referred to such services. Conducting routine, waiting room surveys can provide an easy way of finding out who you need to focus on. Jane Wright, in Guidelines in practice, suggests:

NHS Health Checks: these are 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 relevant.

Quality and Outcomes Framework (QOF): the annual reward and incentive programme for GP practices in England—includes indicators relating to smoking.

Where practices are unable to provide the necessary support or treatment they should refer patients to external services; for example, the NHS’s Smokefree provides information and advice as well as expert support.

 Making the minor interventions matter

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Minor interventions can make a big difference; these include;

  • brief advice to stop smoking;
  • an assessment of the smoker’s interest in quitting;
  • an offer of pharmacotherapy where appropriate;
  • providing self-help material;
  • offering counselling within the practice or referral to external support.

Key here is that advice needs to include an offer of support as this reportedly makes smokers almost twice as likely to make a quit attempt.

The National Centre for Smoking Cessation and training provides a useful demo of how staff can deliver ‘very brief advice on smoking’

Motivational interventions

Smoking cessation can be a sensitive subject – how you approach it is key; motivational interviewing is one technique that can be employed. What does it mean? Essentially, it requires the clinician to explore the patient’s view of their smoking – potentially their ambivalence towards their ‘habit’ – in a way that allows them to clarify what goals are important to them and to organise reasons that support actions.

Questions should be open-ended and you should use affirmations, reflection and summarising – eliciting the course of action from them. For example, ‘Do you see yourself as a life-long smoker?’ or ‘Is there any particular reason you are waiting before you quit?’

Make clear to patients the advantages to their health and discuss barriers to quitting.

Pharmacological support for smoking cessation

When offering advice to a patient available treatments should be detailed so that a well-informed choice about treatment can be made. In Smoking cessation: quick summary, the Primary Care Respiratory Society lists some of the options available – for example, Nicotine Replacement Therapy (NRT), Bupropion (Zyban®) and Varenicline Tartrate (Champix®). These should be used in tandem with intensive behavioural support.

When prescribing, NICE guidelines suggest that you run through the following checklist:

  • Has the patient first been referred to the NHS stop smoking service?
  • Is there a contraindication or potential for adverse effects?
  • What are the patient’s personal preferences?
  • Is the appropriate counselling or support available to support the patient?
  • Will the patient follow the course of treatment?
  • What is the patient’s previous experience of smoking cessation aids?

To vape or not to vape; advice on e-cigarettes

For people who smoke and who are using, or are interested in using, a nicotine-containing e-cigarette on general sale to quit smoking, NICE guidelines say you must explain that, ‘Although these products are not licensed medicines, they are regulated by the Tobacco and Related Products Regulations 2016; many people have found them helpful to quit smoking cigarettes. People using e-cigarettes should stop smoking tobacco completely, because any smoking is harmful. The evidence suggests that e-cigarettes are substantially less harmful to health than smoking but are not risk-free; the evidence in this area is still developing, including evidence on the long-term health impact.’

There is an abundance of information available to support patients to quit; general practice staff can play their part by ensuring that patients have access to the support that they need – be that NHS advice or other cessation resources and a clinical team that is ready to ask the right questions and help patients take the actions they need.

 NICE Guidelines: Stop smoking interventions and services

ASH: Action on smoking and health

Primary Care Respiratory Society (PCRS): Smoking cessation: quick summary

Smoking in England: Smoking Toolkit Study

NHS Health Check

10 self-help tips to stop smoking

British Lung Foundation: How to stop smoking

Office for National Statistics: Adult smoking habits in Great Britain (2014) 

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