Smoking cessation treatment in primary care: prospective cohort study

An observational study of system-level changes to improve the recording of very brief advice for smoking cessation in an inpatient mental health setting

BACKGROUND

Smoking prevalence among people with psychosis remains high. Providing Very Brief Advice (VBA) comprising: i) ASK, identifying a patient's smoking status ii) ADVISE, advising on the best way to stop and iii) ACT (OFFER), offering a referral to specialist smoking cessation support, increases quit attempts in the general population. We assessed whether system-level changes in a UK mental health organisation improved the recording of the provision of ASK, ADVISE, ACT (OFFER) and consent to referral to specialist smoking cessation support (ACT (CONSENT)).

METHODS

We conducted a study using a regression discontinuity design in four psychiatric hospitals with patients who received treatment from an inpatient psychosis service over 52 months (May 2012-September 2016). The system-level changes to facilitate the provision of VBA comprised: A) financially incentivising recording smoking status and offer of support (ASK and ACT (OFFER)); B) introduction of a comprehensive smoke-free policy; C) enhancements to the patient electronic healthcare record (EHCR) which included C1) a temporary form to record the financial incentivisation of ASK and ACT (OFFER) C2) amendments to how VBA was recorded in the EHCR and C3) the integration of a new electronic national referral system in the EHCR. The recording of ASK, ADVISE, ACT (OFFER/CONSENT) were extracted using a de-identified psychiatric case register.

RESULTS

There were 8976 admissions of 5434 unique individuals during the study period. Following A) financial incentive, the odds of recording ASK increased (OR: 1.56, 95%CI: 1.24-1.95). Following B) comprehensive smoke-free policy, the odds of recording ADVICE increased (OR: 3.36, 95%CI: 1.39-8.13). Following C1) temporary recording form, the odds of recording ASK (OR:1.99, 95%CI:1.59-2.48) and recording ACT (OFFER) increased (OR: 4.22, 95%CI: 2.51-7.12). Following C3) electronic referral system, the odds of recording ASK (OR:1.79, 95%CI: 1.31-2.43) and ACT (OFFER; OR: 1.09, 95%CI: 0.59-1.99) increased. There was no change in recording VBA outcomes following C2) amendments to VBA recording.

CONCLUSIONS

Financial incentives and the recording of incentivised outcomes, the comprehensive smoke-free policy, and the electronic referral system, were associated with increases in recording individual VBA elements, but other changes to the EHCR were not. System-level changes may facilitate staff recording of VBA provision in mental health settings.

Appalachian disparities in tobacco cessation treatment utilization in Medicaid

BACKGROUND

Kentucky Medicaid enrollees, particularly those in the rural Appalachian region, face disproportionate smoking rates and tobacco-related disease burden relative to the rest of the United States (US). The Affordable Care Act (ACA) mandated tobacco cessation treatment coverage by the US public health insurance program Medicaid. Medicaid coverage was also expanded in Kentucky, in 2013, with laxer income eligibility requirements. This short report describes tobacco use incidence and tobacco cessation treatment utilization, comparing by Appalachian status before and after ACA-mandated cessation treatment coverage.

METHODS

The study design was a retrospective cross-sectional analysis from 2013 to 2015. Subjects were Medicaid enrollees with 1) diagnosis of any tobacco use (2013 n = 541,349; 2014 n = 864,183; 2015 n = 1,090,274); and/or (2) procedure claim for tobacco cessation counseling, and/or (3) pharmaceutical claim for varenicline or any nicotine replacement product. Primary measures included tobacco use incidence and proportion of users receiving cessation treatment. Analysis was via chi square testing of change by year.

RESULTS

Overall, the proportion of tobacco users utilizing cessation treatment decreased (4.75% tobacco users in 2013; 3.15% in 2015). Tobacco users receiving counseling decreased from 2.06% pre-ACA (2013) to 1.06% post-ACA (2015, p < 0.001), as did the proportion receiving nicotine replacement products post-ACA (2.69% in 2013 to 1.55% by 2015; p < 0.001). More Appalachians received cessation treatment than non-Appalachians in 2013 (2.72% vs. 2.03%), but by 2015 non-Appalachians received more treatment overall (1.50% vs. 1.65%; p < 0.001). Appalachians received more counseling and NRT, but less varenicline, than non-Appalachians.

CONCLUSIONS

Utilization of all forms of tobacco cessation treatment throughout Kentucky, and particularly in rural Appalachia, remained limited despite Medicaid enrollment as well as coverage expansions. These findings suggest that barriers persist in access to tobacco cessation treatment for individuals in Medicaid.

Smoking cessation support for regular smokers in Hungarian primary care: a nationwide representative cross-sectional study

OBJECTIVES

Our study aimed to evaluate the effectiveness of general practitioners' (GPs') smoking cessation support (SCS).

STUDY DESIGN

We carried out a cross-sectional study between February and April 2016.

SETTING AND PARTICIPANT

A sample of 2904 regular smokers aged 18 years or older was selected randomly from 18 general medical practices involved in a national representative, general medical practice-based morbidity monitoring system. The GPs surveyed the selected adults and identified 708 regular smokers.

MAIN OUTCOME MEASURES

Multivariate logistic regression models have been applied to evaluate the determinants (age, gender, education, smoking-related comorbidity, smoking intensity, intention to quit smoking and nicotine dependence) of provision of GP-mediated SCS such as brief intervention, pharmacological and non-pharmacological programmatic support.

RESULTS

According to the survey, 24.4% of the adults were regular smokers, 30% of them showed high nicotine dependence and 38.2% willing to quit smoking. Most of the smokers were not participated in SCS by GPs: brief intervention, programmatic non-pharmacological support and pharmacotherapy were provided for 25%, 7% and 2% of smokers, respectively. Low-nicotine-dependence individuals were less (OR 0.30, 95% CI 0.12 to 0.75), patients with intention to quit were more (OR 1.49, 95% CI 1.00 to 2.22) likely to receive a brief intervention. Vocational (OR 1.71, 95% CI 1.13 to 2.59) and high school education (OR 2.08, 95% CI 1.31 to 3.31), chronic obstructive pulmonary disease and cardiovascular diseases (OR 3.34, 95% CI 1.04 to 10.68; OR 3.91, 95% CI 2.33 to 6.54) increased the probability to receive support by GP.

CONCLUSIONS

Although there are differences among smokers' subgroups, the SCS in Hungarian primary care is generally insufficient, compared with guidelines. Practically, the pharmacological support is not included in Hungarian GPs' practice. GPs should increase substantially the working time devoted to SCS, and the organisation of primary healthcare should support GPs in improving SCS services.

What are older smokers' attitudes to quitting and how are they managed in primary care? An analysis of the cross-sectional English Smoking Toolkit Study

OBJECTIVES

To investigate whether age is associated with access to smoking cessation services.

DESIGN

Data from the Smoking Toolkit Study 2006-2015, a repeated multiwave cross-sectional household survey (n=181 157).

SETTING

England.

PARTICIPANTS

Past-year smokers who participated in any of the 102 waves stratified into age groups.

OUTCOME MEASURES

Amount smoked and nicotine dependency, self-reported quit attempts and use of smoking cessation interventions. Self-report of whether the general practitioner (GP) raised the topic of smoking and made referrals for pharmacological support (prescription of nicotine replacement therapies (NRTs)) or other support (counselling or support groups).

RESULTS

Older smokers (75+ years) were less likely to report that they were attempting to quit smoking or seek help from a GP, despite being less nicotine-dependent. GPs raised smoking as a topic equally across all age groups, but smokers aged 70+ were more likely not to be referred for NRT or other support (ORs relative to 16-54 years; 70-74 years 1.27, 95% CI 1.03 to 1.55; 75-79 years 1.87, 95% CI 1.43 to 2.44; 80+ years 3.16, 95% CI 2.20 to 4.55; p value for trend <0.001).

CONCLUSIONS

Our findings suggest that there are potential missed opportunities in facilitating smoking cessation in older smokers. In this large population-based study, older smokers appeared less interested in quitting and were less likely to be offered support, despite being less addicted to nicotine than younger smokers. It is unclear whether this constitutes inequitable access to services or reflects informed choices by older smokers and their GPs. Future research is needed to understand why older smokers and GPs do not pursue smoking cessation. Service provision should consider how best to reduce these variations, and a stronger effectiveness evidence base is required to support commissioning for this older population so that, where appropriate, older smokers are not missing out on smoking cessation therapies and the health benefits of cessation at older ages.

Access to Subsidized Smoking Cessation Medications by Australian Smokers Aged 45 Years and Older: A Population-Based Cohort Study

Introduction

The principal aim of this study was to assess the accessibility of subsidized cessation medications to socioeconomically disadvantaged smokers, including smokers living in regional and remote communities.

Methods

Analyses used baseline questionnaire and linked Pharmaceutical Benefits Scheme data for 18 686 regular smokers participating in the 45 and Up Study, a large-scale Australian cohort study of people aged 45 years and older. Participants who were dispensed nicotine replacement therapy, varenicline, or bupropion were identified from the Pharmaceutical Benefits Scheme data, which provide an essentially complete record of participants' access to subsidized pharmaceuticals. Associations between the supply of each pharmacotherapy and a range of sociodemographic and health-related variables were evaluated using multiple logistic regression.

Results

The odds that participants were supplied with a cessation medication declined markedly with increasing age for participants older than 60 years and were substantially higher for participants who smoked 20 or more cigarettes/day than for participants who smoked fewer than 10 cigarettes/day. Participants with no formal qualification and those residing in socioeconomically disadvantaged areas had higher odds of receiving nicotine replacement therapy or varenicline than university-educated participants and participants living in the least disadvantaged areas. There was no evidence that participants residing in regional and remote communities had lower odds of receiving a cessation medication than participants residing in major cities.

Conclusions

Older Australian smokers' access to cessation pharmacotherapies is determined predominantly by age and daily cigarette consumption and does not appear to be limited by educational achievement, socioeconomic disadvantage, or remoteness.

Implications

Promoting the use of cessation medications is a principal measure proposed to achieve Australia's National Tobacco Strategy 2012-2018 goal of reducing cigarette consumption among socioeconomically disadvantaged smokers. The results of this large-scale cohort study indicate that access to cessation pharmacotherapies is determined primarily by age and daily cigarette consumption, and is not limited by socioeconomic circumstances, providing some reassurance that existing government subsidies are sufficient to ensure that pharmaceutical aids are accessible to all Australian smokers.

It's time to change the default for tobacco treatment

The World Health Organization estimates that 1 billion people will die from tobacco-related illnesses this century. Most health-care providers, however, fail to treat tobacco dependence. This may be due in part to the treatment 'default'. Guidelines in many countries recommend that health-care providers: (i) ask patients if they are 'ready' to quit using tobacco; and (ii) provide treatment only to those who state they are ready to quit. For other health conditions--diabetes, hypertension, asthma and even substance abuse--treatment guidelines direct health-care providers to identify the health condition and initiate evidence-based treatment. As with any medical care, patients are free to decline--they can 'opt out' from care. If patients do nothing, they will receive care. For tobacco users, however, the treatment default is often that they have to 'opt in' to treatment. This drastically limits the reach of tobacco treatment because, at any given encounter, a minority of tobacco users will say they are ready to quit. As a result, few are offered treatment. It is time to change the treatment default for tobacco dependence. All tobacco users should be offered evidence-based care, without being screened for readiness as a precondition for receiving treatment. Opt-out care for tobacco dependence is warranted because changing defaults has been shown to change choices and outcomes for numerous health behaviors, and most tobacco users want to quit; there is little to no evidence supporting the utility of assessing readiness to quit, and an opt-out default is more ethical.

Feasibility of offering nicotine replacement therapy as a relapse prevention treatment in routine smoking cessation services

Background

National Health Service stop smoking services (NHS SSS) in the UK offer cost- effective smoking cessation services. Despite high abstinence rates after acute cessation treatment, the majority of clients have relapsed by one year. Several interventions have been identified, from trial data, as effective in preventing relapse to smoking. This study investigated uptake, feasibility and acceptability of offering nicotine replacement therapy (NRT) as a relapse prevention intervention (RPI) in NHS SSS.

Methods

Eligible smokers who had successfully completed acute cessation treatment using NRT at Nottingham City NHS SSS between April 2010 and January 2011 were offered the RPI and the rate of uptake was monitored. Consenting individuals completed a baseline questionnaire, providing demographic and smoking behaviour data. The RPI consisted of using NRT for a further 12 weeks after initial cessation-orientated treatment had ended. At a six-month review, self-reported smoking status was assessed via telephone. Anonymised demographic data on NHS SSS users who did not agree to participate in the study were retrieved from NHS SSS records and used to determine the presence of any socio-demographic differences between individuals who agreed to participate in the study and those who did not. Semi-structured telephone interviews were conducted with a selection of participants; these were audio-recorded, transcribed and analysed to identify participants’ views on the RPI.

Results

Of 493 stop smoking service clients who were assessed, 260 were eligible for and offered the RPI and 115 (44%, CI 38%- 50%) accepted. Individuals who accepted NRT were significantly more likely to be older (p < 0.001) and to pay for their prescriptions (p < 0.001). Quitters who had never worked or were unemployed were significantly less likely to accept the offer of relapse prevention compared to those in routine and manual occupations (55% reduction in odds, p = 0.026).

Interview findings revealed that clients who accepted extended NRT felt the longer duration of pharmacological and psychological support were both valuable in helping them to remain abstinent.

Conclusion

In routine smoking cessation service care, it is feasible to offer clients extended courses of NRT as a RPI. The RPI was acceptable to them as almost half of the eligible clients offered this treatment accepted it.

Prevalência da abstinência ao tabaco de pacientes tratados em unidades de saúde e fatores relacionados

O objetivo é conhecer a prevalência e identificar as variáveis relacionadas com a abstinência do tabaco em pacientes tratados nos Grupos de Apoio Terapêutico ao Tabagista (GATT) em unidades de saúde do município de Vitória (ES), no ano de 2009. Estudo transversal com 160 participantes do GATT que participaram de 75% das sessões. Realizada entrevista por telefone, 9 a 20 meses após o tratamento, e usado dados secundários do roteiro de entrevista inicial. Na análise estatística, foram utilizados os testes qui-quadrado e Fisher. A significância estatística foi 5%. Eram abstinentes 28,7%, recaíram 51,9% e 19,4% não pararam de fumar. Houve diferença estatística entre os grupos nas variáveis estado civil (0,039), tentativas anteriores para parar de fumar (0,029), quantidade de cigarros fumados por dia (0,019), uso de fármacos (0,001) e transtorno do humor referidos (0,040). O grupo de abstinente teve mais casados, tentou mais vezes parar de fumar, fumou menos cigarro/dia, apresentou menos ansiedade/alteração do humor. A abstinência foi semelhante a outros estudos e o maior percentual de sujeitos recaiu.

Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance

AIMS

This study aimed to assess the effects of opportunistic brief physician advice to stop smoking and offer of assistance on incidence of attempts to stop and quit success in smokers not selected by motivation to quit.

METHODS

We included relevant trials from the Cochrane Reviews of physician advice for smoking cessation, nicotine replacement therapy (NRT), varenicline and bupropion. We extracted data on quit attempts and quit success. Estimates were combined using the Mantel-Haentszel method and heterogeneity assessed with the I(2) statistic. Study quality was assessed by method of randomization, allocation concealment and follow-up blind to allocation.

RESULTS

Thirteen studies were included. Compared to no intervention, advice to quit on medical grounds increased the frequency of quit attempts [risk ratio (RR) 1.24, 95% confidence interval (CI): 1.16-1.33], but not as much as behavioural support for cessation (RR 2.17, 95% CI 1.52-3.11) or offering NRT (RR 1.68, 95% CI: 1.48-1.89). In a direct comparison, offering assistance generated more quit attempts than giving advice to quit on medical grounds (RR 1.69, 95% CI: 1.24-2.31 for behavioural support and 1.39, 95% CI: 1.25-1.54 for offering medication). There was evidence that medical advice increased the success of quit attempts and inconclusive evidence that offering assistance increased their success.

CONCLUSIONS

Physicians may be more effective in promoting attempts to stop smoking by offering assistance to all smokers than by advising smokers to quit and offering assistance only to those who express an interest in doing so.

The Emergency Department Action in Smoking Cessation (EDASC) trial: impact on delivery of smoking cessation counseling

OBJECTIVES

The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation interventions in the emergency department (ED). The aim of this study was to 1) determine the effect of an emergency nurse-initiated intervention on delivery of smoking cessation counseling based on the 5As framework (ask-advise-assess-assist-arrange) and 2) assess ED nurses' and physicians' perceptions of smoking cessation counseling.

METHODS

The authors conducted a pre-post trial in 789 adult smokers (five or more cigarettes/day) who presented to two EDs. The intervention focused on improving delivery of the 5As by ED nurses and physicians and included face-to-face training and an online tutorial, use of a charting/reminder tool, fax referral of motivated smokers to the state tobacco quitline for proactive telephone counseling, and group feedback to ED staff. To assess ED performance of cessation counseling, a telephone interview of subjects was conducted shortly after the ED visit. Nurses' and physicians' self-efficacy, role satisfaction, and attitudes toward smoking cessation counseling were assessed by survey. Multivariable logistic regression was used to assess the effect of the intervention on performance of the 5As, while adjusting for key covariates.

RESULTS

Of 650 smokers who completed the post-ED interview, a greater proportion had been asked about smoking by an ED nurse (68% vs. 53%, adjusted odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.3 to 2.9), assessed for willingness to quit (31% vs. 9%, adjusted OR= 4.9, 95% CI = 2.9 to 7.9), and assisted in quitting (23% vs. 6%, adjusted OR = 5.1, 95% CI = 2.7 to 9.5) and had arrangements for follow-up cessation counseling (7% vs. 1%, adjusted OR = 7.1, 95% CI = 2.3 to 21) during the intervention compared to the baseline period. A similar increase was observed for emergency physicians (EPs). ED nurses' self-efficacy and role satisfaction in cessation counseling significantly improved following the intervention; however, there was no change in "pros" and "cons" attitudes toward smoking cessation in either ED nurses or physicians.

CONCLUSIONS

Emergency department nurses and physicians can effectively deliver smoking cessation counseling to smokers in a time-efficient manner. This trial also provides empirical support for expert recommendations that call for nursing staff to play a larger role in delivering public health interventions in the ED.

Smoking and health-related quality of life in English general population: implications for economic evaluations

BACKGROUND

Little is known as to how health-related quality of life (HRQoL) when measured by generic instruments such as EQ-5D differ across smokers, ex-smokers and never-smokers in the general population; whether the overall pattern of this difference remain consistent in each domain of HRQoL; and what implications this variation, if any, would have for economic evaluations of tobacco control interventions.

METHODS

Using the 2006 round of Health Survey for England data (n = 13,241), this paper aims to examine the impact of smoking status on health-related quality of life in English population. Depending upon the nature of the EQ-5D data (i.e. tariff or domains), linear or logistic regression models were fitted to control for biology, clinical conditions, socio-economic background and lifestyle factors that an individual may have regardless of their smoking status. Age- and gender-specific predicted values according to smoking status are offered as the potential 'utility' values to be used in future economic evaluation models.

RESULTS

The observed difference of 0.1100 in EQ-5D scores between never-smokers (0.8839) and heavy-smokers (0.7739) reduced to 0.0516 after adjusting for biological, clinical, lifestyle and socioeconomic conditions. Heavy-smokers, when compared with never-smokers, were significantly more likely to report some/severe problems in all five domains--mobility (67%), self-care (70%), usual activity (42%), pain/discomfort (46%) and anxiety/depression (86%). 'Utility' values by age and gender for each category of smoking are provided to be used in the future economic evaluations.

CONCLUSION

Smoking is significantly and negatively associated with health-related quality of life in English general population and the magnitude of this association is determined by the number of cigarettes smoked. The varying degree of this association, captured through instruments such as EQ-5D, may need to be fed into the design of future economic evaluations where the intervention being evaluated affects (e.g. tobacco control) or is affected (e.g. treatment for lung cancer) by individual's (or patients') smoking status.

Who receives prescriptions for smoking cessation medications? An association rule mining analysis using a large primary care database

AIMS

To use association rule mining methods to investigate prescribing of smoking cessation medication in the UK primary care and to identify the characteristics of numerically important groups of patients who typically do, or do not, receive cessation therapy.

DESIGN

An association rule mining study using The Health Improvement Network Database.

SETTINGS AND PARTICIPANTS

282 433 patients aged 16 years and over from 419 UK general practices, who were registered with the practice throughout 2008 and recorded as a current smoker during that year.

OUTCOME

Prescription for any type of smoking cessation medications in 2008 (nicotine replacement therapy, bupropion or varenicline).

VARIABLES

Age, gender, lifestyle indicators and co-morbidity.

RESULTS

Of the current smokers, 37 731 (13.4%) were given prescriptions for smoking cessation treatment during 2008. Prescriptions were particularly likely to be given to women, those aged 31-60 years, and people with diagnoses of chronic obstructive pulmonary disease and depression. On the contrary, of patients with dementia, with alcohol intake over recommended levels, atrial fibrillation or chronic kidney disease was extremely unlikely to be prescribed a smoking cessation medication. However, the largest group of patients who did not receive therapy was young and otherwise healthy individuals.

CONCLUSIONS

This novel approach identified sizeable and easily definable groups of patients who are systematically failing to receive support for smoking cessation in primary care. Association rule mining can be used to identify key numerically important groups at high or low risk of receiving treatment and hence potentially to improve healthcare delivery.

New insights into the sympathetic, endothelial and coronary effects of nicotine

1. Nicotine is a well studied pleiotropic agent which occurs naturally in tobacco smoke and has been largely accused for many of the adverse effects of smoking on the cardiovascular system, including autonomic imbalance, endothelial dysfunction and coronary blood flow dysregulation. 2. The acute sympathoexcitatory effects of smoking on the cardiovascular system are partially mediated by catecholamine release, muscle sympathetic nerve excitation and peripheral chemoreceptor sensitivity increase, consecutive to nicotinic receptor stimulation in the autonomic nervous system. 3. Recent animal data suggest that nicotine promotes the oxidative and inflammatory stress to the endothelium and induces pathological angiogenesis, leading to the progression of the atherosclerotic lesions. 4. Nicotine increases myocardial work without impairing the physiological coronary vasodilatation. Consequently, nicotine per se cannot explain the sudden reduction in coronary flow reserve after exposure to both active and passive smoking. 5. Nicotine's biological effects are characterized by a rapid onset of tolerance, which can explain why nicotine administration does not elicit acute coronary and chemoreflex side-effect in smokers.

Costs and benefits of smoking cessation aids: making a case for public reimbursement of nicotine replacement therapy in Australia

BACKGROUND

Tobacco smoking is the leading preventable cause of morbidity and mortality in Australia and other developed countries. Of the pharmacological aids that are available for smoking cessation, bupropion (Zyban SR) is eligible for public reimbursement on the Australian Pharmaceutical Benefits Scheme (PBS), whereas nicotine replacement therapy (NRT) is not. Information on the cost-effectiveness and financial impact of public reimbursement of these strategies can better inform debate about their inclusion or exclusion in public reimbursement schemes.

OBJECTIVE

To estimate the cost-effectiveness of bupropion and NRT, and the potential financial impact of public reimbursement of NRT in Australia.

DESIGN

A cost-effectiveness analysis using a deterministic Markov model, and cost per disability-adjusted life year (DALY) averted over a lifetime as the outcome measure.

POPULATION

Current smokers, motivated to quit, in Australia in 2000.

INTERVENTIONS

(1) NRT; (2) bupropion; and (3) a combined strategy using bupropion as the first-line treatment and NRT in those who fail to quit smoking or have adverse reactions to bupropion.

RESULTS

Quitting smoking can increase life expectancy of current smokers by 1-7.6 years depending on age at cessation and sex. Providing bupropion to current smokers who are motivated to quit would cost A$7900 (95% uncertainty interval A$6000 to A$10,500) for each DALY averted; NRT patches would cost A$17,000 (A$9000 to A$28,000) for each DALY averted, with similar results even if used as a second-line treatment following initial failure to quit using bupropion. If 6% of current smokers were to use NRT following inclusion on the PBS, this would result in an annual cost of A$40-110 million to the PBS depending on the listed price.

CONCLUSIONS

Compared with other drugs included on the PBS, bupropion and NRT are both highly cost-effective smoking cessation interventions, and including NRT on the PBS would have a moderate financial impact. Given the sizeable health burden of smoking, and the large individual benefits of quitting smoking, increasing the availability of alternative aids and uptake of these strategies through public reimbursement would be a positive and rational step towards further reducing tobacco-related disease burden in Australia and other countries where NRT is currently not subsidised.

Drugs to support smoking cessation in UK general practice: are evidence based guidelines being followed?

BACKGROUND

Prescribing drugs to support smoking cessation is one of the most cost effective interventions in primary care, but there is evidence they are underused. Little is known about how far guidelines have been adopted.

AIMS

To examine the context in which nicotine replacement therapy (NRT) and bupropion are prescribed in UK general practice and whether guidelines are being followed.

DESIGN

Patient questionnaire survey.

SETTING

Twenty five general practices from the Trent Focus Collaborative Research Network in South Yorkshire and East Midlands, UK.

METHODS

Participating practices posted a questionnaire to up to 40 patients prescribed NRT and bupropion respectively in the previous 3-9 months.

RESULTS

The response rate for people prescribed NRT was 44.7% (323/723) and for bupropion 42.5% (77/181). Patients reported initiating the prescription request in 258 cases (65%), whereas GPs were reported as suggesting it in 49 (12%), smoking cessation services (SCS) in 38 (10%), and practice nurses in 36 (9%). Of those who could recall the content of the consultation in which NRT or bupropion was prescribed, 191 (79%) reported receiving advice on treatment use and 209 (68%) were encouraged to set a quit date. Follow up by SCS was recommended to 186 (64%) and practice follow up was offered to 212 (63%), but 41 (15%) reported no offer of follow up support.

CONCLUSIONS

The majority of patients reported receiving advice and follow up in line with guidelines. However, relatively few prescriptions were suggested by GPs or practice nurses and, in a significant minority of cases, neither follow up by the practice nor additional support from SCS was recommended. More active implementation of guidelines could increase the impact of general practice on the prevalence of smoking.