How to provide effective smoking advice

How to provide effective smoking advice - in less than a minute without offending the patient

Author John Litt Department of Emergency and Primary Care Noarlunga Hospital Noarlunga, South Australia 5168 Email: jlitt@flinders.edu.au Background General practitioners have the opportunity, credibility and authority to provide smoking cessation advice and are effective in assisting smokers to quit. Despite their potential, GPs identify just over half the smokers in their practice and counsel approximately one-third to quit. Implementation of smoking cessation advice has not improved in the past 10 years despite the availability of evidence based guidelines. Effective smoking cessation advice should include both the 5As (Ask, Assess, Advise, Assist, Arrange) and the development of a supportive infrastructure within the practice setting. Objective This article outlines the rationale for GP involvement in assisting smokers to quit, advises how GPs can provide smoking cessation advice in less than a minute, the main barriers to quitting smoking, and the core activities in the 5As. Discussion General practitioner effectiveness in smoking cessation can be improved by adopting a systematic approach to identifying smoking status, more effective engagement of smokers by separating information from the 'moral imperative', use of brief motivational interviewing techniques and appropriate pharmacotherapy, and use of the QUIT line and other smoking cessation resources. Smoking is the largest single preventable cause of death and disease in Australia. No other single avoidable factor accounts for such a high proportion of deaths, hospital admissions or general practitioner consultations.¹ Smoking is a major risk factor for a number of diseases and disabling conditions (Figure 1). Life long smokers have a 50% change of dying from a tobacco related disease, half of these deaths will occur in middle age (25-54 years).¹ Approximately 22% of the population are smokers; of these, just over half are seriously thinking about quitting in the next six months and a similar number have made a quit attempt in the past 12 months.² A strong case has been made to regard smoking as a chronic relapsing drug dependency.³		Why GPs? General practitioners can have a significant impact on assisting patients who smoke to quit. General practitioners have the: • opportunity - 80% of Australians visit their GP at least once per year⁴ and, on average, make five visits in this time period⁵ • credibility - patients see GPs as having a key and supportive role in smoking cessation⁶ and expect advice from them⁷ • effectiveness - a range of systematic reviews have shown that brief, repeated, nonjudgmental advice by a primary care physician is effective in assisting patients who smoke to quit.⁸ The unsupported quit rate is approximately 3%;¹ GPs can improve this 8-fold (up to 24%) by using a combination of the strategies listed below over several visits^1,9 • feasibility - brief advice is feasible and can take less than one minute¹⁰ • efficiency - smoking cessation counselling is both cost effective and worthwhile and can be incorporated into the practice routine.^6,11 Implementation of smoking cessation advice has not improved in the past 10 years despite the availability of evidence based guidelines. What are the barriers? System barriers • Adhoc approach.¹³ Only half of patients are asked about their smoking and only a third of this group are counselled¹⁴ • Limited GP disposable time (on average, 30-60 seconds with a range of minus 2 hours to 5 minutes at best) to address smoking cessation affectively when it is not on the patient agenda^11,14 • Lack of supportive infrastructure¹⁵ to assist GPs to: - identify ALL patients who smoke - determine interest in quitting - target advice to those most receptive - provide QUIT materials to complement advice to quit • The limited awareness and use of referral options such as the QUIT line.¹⁵ Patient barriers • Smoking cessation is both complex and difficult^1,16 - nicotine is more addictive than heroin¹⁷ - most patients make 5-8 quit attempts before they finally succeed - the unsupported quit rate success is approximately 3%¹ - less than half of smokers ultimately succeed in quitting before they reach 60 years of age¹ • Cigarettes become an integral part of a smoker's life making it difficult for smokers to imagine life without cigarettes¹⁶ • Only half the smoking population consistently express an interest in quitting¹⁸ • Reluctance to seek assistance even when interested in quitting¹⁶ - concern about being judged when they do seek help - a belief that they should be able to quit without help - seeking help is often seen as using a crutch or a sign of no willpower.¹⁶