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

• Set a quit date
• Give practical advice about coping with withdrawal symptoms (Table
   2)
• Highlight the benefits of quitting (see Patient education). Smokers often
   focus on the negative aspects of quitting, e.g. withdrawal symptoms
   (craving, irritability, sleep disturbance), initial worsening cough, weight
    gain. It is important to provide some balance. Many of the positive
   aspects are not visible, e.g. improved arterial circulation, declining risk
   of a heart attack or lung cancer, improved wound healing. Give them
   the Patient education hand-out to highlight the many advantages that
   accrue with continuing abstinence.

Assist
• Offer self help material, eg. quit book or QUIT line card
• Assist in setting a quit date and helping the patient develop a plan
• Explore potential barriers and difficulties and brainstorm solutions.
   Address the three areas that undermine success: withdrawal
   symptoms, the habit and dealing with negative emotions
• Review the need for pharmacotherapy and discuss type, common side
   effects and dosage. Remember that most NRT products deliver less
   nicotine than cigarettes (Table 3).

Arrange
• Referral to a QUIT line 131 848
• Support. If the person's partner is also a smoker then a quit attempt by
   both at the same time doubles the success rate for both
• A follow up appointment. The relapse rate is highest in the first seven
   days. Offering a follow-up appointment helps shore up the patient's
   resolve to get over this immediate period. Use the follow up
   appointment to adjust pharmacotherapy or deal with high risk 
   situations.
Developing a supportive organisational infrastructure
While all practices have an organised billing system to ensure they get paid, few translate this systematic approach to ensuring the delivery of
high quality clinical care.21,22,26 The RACGP23 have assisted GPs in this area with the publication of the evidence based monograph Putting Prevention into Practice (also known as the 'Green book'). The CREATE framework operationalises the core tasks and activities that are required for effective implementation of preventive activities, including smoking cessation (Figure 2).27,28

Conclusion
General practitioners can provide effective advice to smokers in less than one minute in the general practice setting. The 5As encapsulate the core activities necessary for smoking cessation, while the RACGP 'Green book' and the CREATE framework provide the supportive environment to make smoking cessation possible.

Acknowledgments
Tania Shelby-James (Senior Project Officer with GASP: GPs Assisting Smokers Program) and David Edwards (Senior Project Officer, QUIT SA) helped to set up the GASP Consortium and assisted with the development of the GASP materials. The GASP consortium included
representatives from a range of groups (RACGP, AMA, Flinders and Adelaide Universities, QUIT SA, Anti Cancer Council, Asthma Foundation, National Heart Foundation, SA Divisions Inc, Rural Doctors Association and DATIS) with an interest in assisting clinicians to be more effective in smoking cessation. Many of the practical suggestions outlined in this article emerged from this group. The GP Reference Group who reviewed earlier versions of the material are: Dr Cathy Sanders, Dr Michael Taylor, Dr James Asimakopolous, Dr Bob Reissen, Dr Georgina Moore, Dr Peter Morton and Dr Deborah Kerrigan.

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