While the British Heart Foundation designates March 12th No Smoking Day, promotion of smoking cessation remains an everyday challenge for GPs. Here, Professor Robert West, from University College London’s Department of Epidemiology and Public Health, argues that we may be able to achieve more by doing less.
Smoking prevalence is declining steadily and is now less than 20% in England for the first time in probably 80 years. 1 But that still means that almost 1 in 5 patients smoke (about 10 million in the UK), and half of these will die prematurely if they don’t stop – many in their forties and fifties.
GPs have been at the forefront in encouraging and supporting patients to stop and are cited by smokers as the single most common trigger for quit attempts. But there is much more that can be done, and evidence is now suggesting that we can get better outcomes with less time and in a conversation that is more comfortable for all concerned.
New research is showing that the traditional approach of raising the topic of smoking, advising smokers to stop and then offering help if they express an interest can be replaced by a simpler, quicker and more effective style of conversation. Many GPs are already doing it. With this new approach, GPs do not advise smokers to stop – or even ask them whether they have thought about stopping; they simply offer advice on the options available if they want to stop, focusing on the combination of professional support and one of the stop-smoking medicines. They then ask the smoker if he or she would like to speak to a trained advisor. If the smoker expresses an interest, an appointment is made. If the smoker declines the offer, new NICE guidance recommends concluding the conversation by suggesting to the smoker that they try to cut down using one of the licensed nicotine products available. 2 This guidance is based on evidence that cutting down with the help of a nicotine product increases the chances of quitting further down the line.
The key piece of research behind this change of tack is a meta-analysis of clinical trials on physician advice to promote smoking cessation. The findings showed that it was the offer of help that had the largest effect – not the advice to quit.3 There is also survey evidence that smokers who report that they have been offered help with quitting are more likely to try to quit than those who were just advised to stop (www.smokinginengland.info). Anecdotal evidence from GPs who use this approach also suggests that it makes for a much more friendly and positive interaction.
There is an online training video available via BMJ Learning (www.learning.bmj.com), commissioned by the Department of Health to show this approach, known as VBA (Very Brief Advice). The training video takes only 30 minutes to watch and has been very well received by GPs. In addition, since January of this year smokers can get hold of a book on what the evidence tells us are the best ways of stopping and how to get the best out of them. It’s called The SmokeFree Formula (Orion Books) and GPs and stop- smoking services in some areas are starting to use it with their patients.
So there is still much to do in encouraging and supporting smokers to stop. GP advice is having a substantial impact, but there is reason to believe that we can achieve more with less by just offering support to all smokers which they can then take or leave as they wish.
1. Brown J, West R. Br Medical J. 2004:348; g1378.
2. National Institute for Health and Care Excellence (2013) Tobacco Harm Reduction (PH45). London: NICE.
3. Aveyard P, Begh R, Parsons A, West R. Addiction (2012):107;1066-73.