General Practice has undergone massive changes in service delivery during the COVID-19 pandemic. We have had to adapt to telephone and video consultations at an extremely rapid speed.
It’s been a crucial task of providing healthcare while not missing any red flags in these challenging times, and it’s clear that remote consultations are here to stay. However, the risk with remote consultations is that lifestyle-related preventive health discussions can often get missed.
COVID-19 has also laid bare the impact of health inequalities on some of our most socially and economically disadvantaged communities. While the government initiatives on obesity prevention will benefit these communities, in whom incidence of obesity is often higher, I fear that some other endemic lifestyle issues including smoking cessation might be overlooked.
Ill effects on physical and mental health from smoking are not easily visible in early stages and hence, despite smoking costing the NHS in England around £2.4bn, with nearly half a million hospital admissions in England being attributable to smoking, smoking often is perceived to be relatively less harmful.
However, smoking is the leading cause of ill-health, premature death and a key driver of health inequalities. Overlooking smoking cessation will therefore disproportionately affect some of our most socially marginalised communities.
I recently co-authored a paper, published in the journal Drugs and Alcohol Today, that looked into neglected subgroups of populations with disproportionately high smoking rates. We observed that social marginalisation is a shared and important determinant of smoking prevalence.
These groups of populations find using mainstream cessation support particularly difficult. In the UK, people with mental health conditions, people from black, Asian and minority ethnic (BAME) communities as well as lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) communities are such groups whose health needs are often neglected.
Mental health patients form a third of the UK’s current smokers. Even in pre-COVID-19 times, mental health patients often struggled to quit smoking. Smoking is so common in some mental health conditions (>70% patients with schizophrenia smoke), that it is often accepted and expected in mental health patients.
The COVID-19 pandemic continues to affect people’s mental health significantly with worsening anxiety and depression - both of which are common triggers for smoking more or relapsing back to smoking.
People from BAME communities living in Britain are at a higher risk of a number of smoking related diseases than white Britons. Those already more susceptible to these diseases further increase their chances of ill-health if they smoke.
Also, other forms of risky tobacco use such as smokeless tobacco (SLT) and shisha use is common in BAME communities. Many people in these groups also face challenges like language barriers and lack of specialist advice around oral tobacco use cessation.
NICE guidance notes that reducing smoking prevalence among some ethnic minority groups would reduce health inequalities more than any other measures. In the current pandemic, it is seen that the death rates from COVID-19 are higher for BAME groups when compared to white ethnic groups.
Similarly, LGBTQ groups in the UK are more likely to smoke than the national average and hence are at higher risk of smoking related diseases including heart and lung diseases, and cancer.
Young LGBTQ people are also more likely to smoke, start smoking at a younger age and smoking more heavily. LGBTQ people often report limited access to health services. It is recommended that good communication with the LGBTQ community encourages them to be involved in their own healthcare and promotes better health outcomes.
The news that about around 1m smokers quit during the COVID-19 pandemic is definitely very positive, especially as smokers are at a higher risk of complications from the virus.
This news, however, is based on a survey of a representative sample of 10,000 from the population - we still don’t have actual numbers of people who have quit. Also ‘relapse’ is unfortunately very common among ex-smokers and likely to be worsened with the persistent economic uncertainty, stress and anxiety.
In these unprecedented times, using the best practice tools, we GPs are best placed to proactively discuss tobacco cessation with all patients, and especially with people from these groups. These people often don’t proactively access mainstream stop smoking clinics due to multiple barriers but are seen by GPs regularly.
Indeed, data suggests that people in England who smoke see their GP over a third more than those who don’t smoke. GPs should also ensure that the practice staff are trained with the latest evidence-based smoking cessation tools to support every smoker patient, during every patient contact, to quit smoking.
Every member of society has a right to live a long, healthy and happy life and we GPs and our teams are in a privileged position to help them get there.
- Dr Pooja Patwardhan is a practising GP in Hampshire. She is also a co-founder and Medical Director of the Centre for Health Research and Education (CHRE), an independent healthcare company based at the University of Southampton Science Park, Chilworth, Southampton. CHRE's mission is to prevent cancer globally, by empowering healthcare professionals with the latest evidence-based approaches to smoking cessation and childhood obesity prevention.