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Putting smoking cessation into practice

Patricia Hodgson
MSc Nutrition
Health Promotion Specialist Calderdale and Kirklees Smoking Cessation Service Princess Royal Health Centre Huddersfield
West Yorkshire Smoking and Health Coordinator

Never has there been so much positive news for practitioners regarding smoking cessation. Helping people stop smoking is at the top of the government's health agenda.(1-3) All health authorities throughout England have set up smoking cessation services, whose activities include supporting primary healthcare teams in their smoking cessation efforts.(4) Primary care is at the cornerstone of these services.(3)
National smoking cessation guidelines and quality standards are available to guide practitioners in providing effective interventions.(5) Smoking cessation is the "gold standard" of preventive interventions. Considered highly cost-effective, smoking cessation costs less than £900 per discounted life-year gained. This compares favourably with most healthcare procedures; the median cost of over 310 medical interventions has been estimated to be £17,000 per life-year gained.(6)
User-friendly resources are available to help ­practitioners translate complex guidelines into helpful interventions.(7) Nicotine replacement therapy (NRT) and the new non- nicotine medication amfebutamone (formerly bupropion) are now available on the NHS. This is good news for low-income smokers as ­pharmacological therapies have been found to double success rate.(5)
The free NHS Smoking Helpline (0800 169 0 169) is available to provide support to both patients and ­practitioners. Over 70% of smokers want to stop, and many want help in doing so.(5) Practitioners do not have to look for smokers to help; they'll find ready customers in their waiting rooms (see Table 1).

[[NIP01_table1_51]]
 
GPs and practice nurses believe it is their role to advise and assist smokers to stop.(8) Training for health professionals in delivering smoking cessation programmes, based on the widely acceptable "Helping People Change" model, is now readily ­available either through local health promotion ­services (such as the Royal College of Nursing and the Smoking Cessation Training and Research programme at St Bartholomew's & the Royal London School of Medicine), smoking cessation services or other national training organisations.(9)

The downside
Now for the disappointing news. Although there is a considerable amount of activity taking place to help people quit smoking, the level in primary care is below that recommended in the National Guidelines.(5,8) This is not surprising. Simply ­publishing and disseminating information and ­providing training in the delivery of smoking ­cessation does not guarantee an increase in the ­number of interventions.(10) And in practices where high levels of activity exist, that ­activity faces a fate similar to that of many other attempts to deliver clinical ­interventions in general practice in the past - simply fading away with time.(11)
So why is the level of smoking cessation activity in primary care not as high as recommended? And why is it at risk of fading away? In many cases it is not the busy practitioner who is to blame for this, but the inadequate systems.(12,13) According to Ockene, a well-known smoking cessation expert: "effective interventions in smoking cessation exist, but they're not achieving their full potential because of inadequacies in their delivery system".(14)

Smoking Cessation in Practice (SCIP)
So how can practices ensure that they have an ­adequate system in place? Is there any help in doing so? A resource, Smoking Cessation in Practice (SCIP), has been developed to guide practitioners in developing an effective system tailored to the needs of their practice.(15-17) It helps assess the smoking cessation ­system in place, identifies strengths and weaknesses, and suggests ways to develop a system for routine, organised, efficient and sustainable smoking cessation. 
Table 2 lists the nine components necessary to successfully implement a smoking cessation system, as identified by SCIP. Each of these components is an essential link in the delivery chain. It just takes one weak link to reduce the number of people being offered help and support.

[[NIP01_table2_52]]
 
SCIP puts these components into a framework, identifies preconditions that need to be in place to make it easier to improve your practice's systems, and provides a process for putting these components into place. Many practices that have used SCIP to improve their smoking cessation support have gone on to use the framework in improving their system for delivering other preventive services.

Conclusion
There has never been such a good time for practitioners to tackle smoking. Most smokers want to stop and would benefit from empathetic help. A wealth of ­support and user-friendly resources exist to help. But your efforts are likely to fade with time if you do not ensure that an ­effective system is in place to make smoking cessation a part of the fabric of your services.

[[NIP01_pp_53]]

References

  1. Department of Health. Smoking kills: white paper on tobacco. London: HMSO; 1998.
  2. Department of Health. National Service Framework for coronary heart disease. London: HMSO; 2000.
  3. Department of Health. The NHS Plan. London: HMSO; 2000.
  4. Department of Health. The new NHS smoking cessation service. Health Service Circular 1999/097. London: Department of Health; 1999.
  5. West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax 2000;55:987-99.
  6. Parrott S, Godfrey C, Raw M. Guidance for commissioners on the cost effectiveness of smoking cessation -interventions. Thorax 1998;53(Suppl. 5):S1-38.
  7. Hodgson P. Smoking cessation on the card. Healthlines 1997;May:10-11.
  8. McEwen A, West R. Smoking ­cessation activities by general ­practitioners and practice nurses. Tobacco Control 2001;10:27-32.
  9. Bain N, McKie L. Stages of changes of change training for opportunistic smoking intervention by the primary health care team. Part 2: qualitative evaluation of long term impact of professionals' reported behaviour health. Health Educ J 1998:57:150-9.
  10. Silagy C, Lancaster T, Fowler G, Spiers I, editors. Effectiveness of ­training health care professionals to provide smoking cessation interventions. The Cochrane Library, Issue 2. Oxford: Update Software 1998.
  11. Nuffield Institute for Health, University of Leeds, Centre for Health Economics, NHS Centre for Reviews and Dissemination. Effective healthcare: implementing clinical practice guidelines. Leeds: University of York; 1994.
  12. Solberg L, Kottke T, Conn S, Brekke M. Delivering clinical preventive services is a systems problem. Ann Behav Med 1997:19(3):271-8.
  13. US Department of Health and Human Services. Smoking cessation: a systems approach. Rockville, MD: US Public Health Service; 1997.
  14. Ockene J. Changing provider behaviour: provider education and training. Tobacco Control 1997;6(Suppl. 1):S63-7.
  15. Hodgson P. Smoking cessation in practice: creating systems for delivering National Smoking Cessation Guidelines - Quick Reference Guide. Huddersfield: Huddersfield NHS Trust; 2000.
  16. Hodgson P. Getting to grips with smoking cessation. Practice Nurse 1999;18(7):441-3.
  17. Hodgson P. Smoking cessation in practice. Conference report. Leeds: West Yorkshire Smoking & Health; 1999.

Resources
British Lung Foundation
W:www.lunguk.org
NHS 'Don't give up giving up' resource
W:www.givingupsmoking.co.uk
Smoking Cessation Advice in a Nutshell West Yorkshire Smoking & Health Available from GASP
T:0117 9425185

Further reading
Dickey L, Gemson D, Carney P.
Office system ­interventions supporting primary care-based health behaviour change counselling. Am J Prev Med 1999;17:299-304.
Doll R, Crofton J. Tobacco and health. Br Med Bull 1996;52(1).
Edwards R, Brown J, Hodgson P. An action plan for tobacco control at regional level. Public Health 1999;113:165-70.
McNeill A, Bates C. Smoking cessation in primary care:how to do more for health than the available resources in the NHS. London:ASH; 2000.
NHS Centre for Reviews & Dissemination. Effective
healthcare: getting evidence into ­practice. York: University of York; 1999;5(1):1-16.
Royal College of Physicians. Nicotine addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. London:Royal College of Physicians; 2000.