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Nicotine, the oft forgotten drug |
Not only is nicotine an addictive drug, but current marketing (eg. sports sponsorship and incidental appearances in movies) and merchandising (eg. attractive packaging and supermarket placement) can still make it difficult for smokers to quit.
The recently released occasional paper from the National Tobacco Strategy 1999 to 2002-3 “Smoking Cessation Interventions” reviewed the evidence and implications for best practice.
The paper found a small advantage of intensive cessation advice provided to smokers by their GP over minimal clinical advice. Minimal clinical advice consists of opportunistic brief cessation advice delivered during routine consultations to smokers as to whether or not they are seeking help with stopping smoking.
Each session usually lasts three to five minutes and follows a stepped process described as the 5 As approach.
1. Ask about tobacco use
Implementing clinic systems (eg. nurse assessments, recalls) designed to increase the assessment and documentation of tobacco use almost doubles the rate at which GPs intervene with their patients who smoke and results in higher rates of smoking cessation.
2&3. Advise & Assist
Opportunistic brief cessation advice to smokers delivered during routine consultations has an immediate modest effect size, but substantial potential public health impact. A major benefit is to motivate a quit attempt and to provide support or referral to aid quit attempts.
4. Assess
Assessment of readiness to quit is a necessary first step in planning. However assessment of individual and environmental attributes is not essential for effective intervention but may provide information for tailoring treatment. Tailoring materials to the characteristics of individual smokers improves effectiveness.
5. Arrange follow-up
Assessment within the first week after quitting is desirable to support quit attempts. Relapse prevention therapy reduces relapse rate and support of relapsed smokers to make another quit attempt is effective.
Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice.
Brief advice from GPs (taking around three minutes) decreased the proportion of people smoking by around two per cent per year.
Increasing the intensity of advice (time spent giving advice and the duration of follow-up) decreased the proportion of smokers by around three to five per cent per year.
Follow-up visits with their GP significantly increased cessation rate of smokers at six months or more compared to no follow-up.
Repeated telephone support by a nurse after an initial intervention by a GP appears to increase long-term cessation rates.
The effect of intensive counselling compared to minimal counselling by a GP was greater in trials with patients with, or at high risk of, smoking related disease.
GPs appear to be more willing to give advice to stop to smokers with smoking related diseases. This is despite evidence that smokers with smoking related diseases do not respond better to such advice than others.
There is some evidence that smokers are happier to receive advice to stop when GPs link the advice to their reason for visiting the surgery, even if the reason for the visit is not smoking related.
Smoking interventions by nurses in seven trials with non-hospitalised adults gave an estimated 50% increase in the odds of success, including when combined with GP advice.
Almost 20% of Australian GP patient encounters are with daily smokers, and an additional 5% are with occasional smokers. Australian GPs identify two thirds of their patients who smoke but advise only half of these to quit. Rates of detection and cessation advice have not changed in ten years.
As well as its direct effect, advice from a GP to quit smoking has a priming effect on patient responses to other smoking cessation interventions.
Nicotine replacement therapy doubles the odds of quitting and this is increased when combined with pharmacotherapies (eg Zyban).
A systematic approach to ascertaining and documenting patients’ tobacco use is the first step in changing clinical culture and practice patterns to ensure that every patient who smokes is offered treatment.
The evidence for the effect of provider reminder systems for identifying smokers on cessation attempts is strong. This is a relatively simple intervention that can be incorporated into the routine practice of most practices in Australia.
Ways to improve smoking cessation rates in your smoking patients
- Provide intensive advice
- Link quit advice with reason for visiting surgery
- Consider GP plus practice nurse intervention
- Consider nicotine replacement therapy
- Put reminder systems in place
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