Sponsored article: Primary care can't quit on smokers

As the demand for smoking cessation seems to stall, primary care professionals have a crucial role to play in helping patients quit smoking.

On 1 July 2007, England introduced a new law to make all enclosed public places and workplaces smoke free.

Following similar bans in the rest of the UK and Europe, the new law was part of the government's plans to reduce adult smoking rates from 26 per cent in 2002 to 21 per cent or less by 2010.

The government estimated that the ban would make up to 600,000 people decide to quit smoking.

According to statistics, over 150,000 people set a quit date through NHS Stop Smoking Services in the three months leading to the smoking ban - an increase of 11 per cent over the same period in 2006/7 and 5 per cent over the same period in 2005/06 [1].

Now in the year following its implementation, the new law seems to have been well received. Recent research shows that 75 per cent of people support the ban, including 84 per cent of non-smokers; and a greater proportion of smokers (47 per cent) support the ban than oppose it (37 per cent). Almost 80 per cent of people surveyed after 1 July think it will have a positive effect on people's health [2].

Primary care staff need to revive initial quitting rush
Smoking cessation services as well as primary care saw an increase in the number of smokers looking for advice on quitting just before and after 1 July.

However, it seems that the initial quitting rush has given way to a slow down and this is why clinicians still have a crucial role to play in helping people willing to quit smoking [3].

Practitioners should be aware of NHS Stop Smoking Services, the different ways to stop smoking (stopping abruptly, combination therapy, and the 'cut down, then stop' technique), the different medications that can help, and the complementary behavioural support programmes that can improve patient confidence and concordance.

NICE has set out guidance for brief interventions and referral for smoking cessation in primary care which recommends that all smokers should be advised to quit smoking, not just those who are already ill [4].

According to the NICE guidance, brief interventions should be opportunistic and for smoking cessation should take only 5 or 10 minutes. The solutions offered to the patient should be based on each individual and will depend on their willingness to quit, whether they find the intervention offered acceptable and the previous methods they have tried to give up smoking.

In brief, NICE recommends that:

  • Everyone who smokes should be advised to quit, unless there are exceptional circumstances.
  • People who smoke should be asked how interested they are in quitting.

Healthcare professionals should take the opportunity to advise all patients who smoke to quit when they attend a consultation. Those who want to stop should be offered a referral to an intensive support services (for example, NHS Stop Smoking Services).

If a patient is unwilling or unable to accept a referral then patients should be offered pharmacotherapy in line with NICE recommendations.

The guidance provides a simple and effective method of reaching as many patients as possible. Maintaining these opportunistic interventions will ensure that referral to Stop Smoking Services will continue, helping, in part, to prevent the tail off of demand experienced in Scotland.

The guidance text was recently updated to include new advice on the use of varenicline (Champix) for smoking cessation and to incorporate MHRA advice, which states that nicotine replacement therapies (NRT) may be used in combination. The next revision is planned for 2009.

Pharmacotherapy can increase the chance of success and, preferably, should be offered alongside behavioural therapy. The main options are NRT (including patches, lozenges, nasal sprays), bupropion (Zyban) and varenicline.

The main goals for the smoking-cessation interventions that can be carried out in primary care are outlined in table 1.

Table 1: Goals for primary care actions to support smoking-cessation strategies



Recording of patient-specific smoking information (smoking status, advice, referral, drug treatments)

To enable smoking-cessation strategies to be adjusted according to clinical audit

Opportunistic brief advice to current smokers

To trigger an attempt to quit

Referral to smoking-cessation service

Complete abstinence

Drug treatments (nicotine replacement therapy and bupropion)

Complete abstinence

Opportunistic brief advice to ex-smokers

To prevent (or delay) relapse

Source: Clinical Knowledge Summaries service (CKS)

For GPs in particular, an indicator for smoking was added to the new GMS contract revised in April last year. GPs are encouraged to record and advise smokers with coronary heart disease, stroke or TIA, hypertension, diabetes COPD or asthma with the incentive to earn up to 68 quality points, which represents almost £8,500 a year for a standard practice (see table 2).

Table 2:Quality & Outcomes Framework (QOF) April 2006 - March 2007
Clinical Domain - Smoking



Payment Stages

Smoking 1: The percentage of patients with any or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD or asthma whose notes record smoking status in the previous 15 months. Except those who have never smoked where smoking status need only be recorded once since diagnosis



Smoking 2: The percentage of patients with any or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD or asthma who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months



Meanwhile, guidance on Stop Smoking Services for pharmacists was launched in August [5].

The guidance, called 'Towards a smokefree England - brief interventions for stopping smoking by pharmacists and their staff', was developed by PharmacyHealthLink in conjunction with the DoH.

It includes a summary of NICE recommendations on smoking cessation services and lists further sources of information for pharmacists to use.

The guidance was mainly planned for use by community pharmacy staff but PharmacyHealthLink thinks it is suitable for other pharmacy staff, such as in hospitals or primary care.

Further resources

1. Statistics on NHS Stop Smoking Services in England, April to June 2007 (consulted on 28 November 2007)

2. NHS Smokefree England - Latest research

3. The Pharmaceutical Journal, Vol 279 No 7468 p252, 8 September2007

4. NICE guidance

5. The Pharmaceutical Journal , Vol 279 No 7464 p146, 11 August 2007

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