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Lifescripts methodology card: smoking

Helping patients quit smoking.

Lifescripts methodology card: helping patients quit smoking (PDF 100 KB)

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html version of smoking methodology card

Ask, assess, advise, assist, arrange
Evidence for the benefits of quitting

Ask, assess, advise, assist, arrange

Ask

Less intensive (1-5 mins)

Identify all smokers in your practice¹

• Waiting room checklist and poster
• Patient record prompts: check lifestyle habits at least every two years
• Prompts by practice staff

Ask: 'How do you feel about your smoking at the moment?'

More intensive (5-15 mins)

Identify all smokers in your practice¹

• Waiting room checklist and poster
• Patient record prompts: check lifestyle habits at least every two years
• Prompts by practice staff

Ask: 'How do you feel about your smoking at the moment?' Top of page

Assess

Less intensive (1-5 mins)

Assess interest in quitting

• Assess:
  • nicotine dependence - if high dependence consider more intensive intervention
  • interest and confidence in quitting

Ask: 'Are you willing to give quitting a try?'

• Assess barriers to quitting (e.g. 'What would be the hardest thing about quitting?')
• Record lifestyle habits in patient's record

More intensive (5-15 mins)

Assess current smoking and interest in quitting

• Smoking assessment tool:
  • nicotine dependence (first cigarette <30 minutes after waking, >10 cigarettes per day, history of withdrawal symptoms)
  • interest and confidence in quitting
• Assess habit
• Assess psychological triggers e.g. negative emotions (boredom, anger, worry/ anxiety, depressed)
• Ask about quitting history: what caused past relapses? What situations tempt the person to smoke?
• Identify individual barriers to quitting
• Assess mental health status
• Record lifestyle habits in patient's record Top of page

Is the person ready to attempt quitting?

If yes, ready to attempt change, continue with the 5As approach

If no, not ready

• Advise on benefits of quitting
• Offer information and quit book
• Assess interest in quitting at later date

Advise

Less intensive (1-5 mins)

Advise on benefits of change

• Provide brief, non-judgemental advice about positive benefits of quitting

More intensive (5-15 mins)

Provide tailored advice

• Provide brief, non-judgemental advice to quit
• Discuss benefits to individual of quitting
• Set quit date Top of page

Assist

Less intensive (1-5 mins)

Offer resources and support

• Offer Quit because you can book
• Refer to Quitline 13 QUIT (13 7848)
• Encourage social support

More intensive (5-15 mins)

Write smoking cessation prescription

• Jointly devise strategies for support
• Individualise the prescription (incl. goal setting)
• Make an individual plan to deal with common challenges e.g. withdrawal, habit, mood, weight gain, stress, smoking triggers and high-risk situations
• Prescribe medication: nicotine replacement therapy and/or varenicline or bupropion for dependency²
• Offer Quit because you can book
• Refer to Quitline 13 QUIT (13 7848)
• Encourage social support Top of page

Arrange

Less intensive (1-5 mins)

Arrange follow-up

• Negotiate a separate consultation about smoking
• Organise follow-up review

More intensive (5-15 mins)

Arrange referral and follow-up

• Refer to the active call-back Quitline program (use fax referral)
• Recruit support (e.g. partner or family)
• Organise follow-up in seven days (or soon after quit date)
• Negotiate a separate consultation to discuss quitting Top of page

Evidence for the benefits of quitting *

Why quit?

Smoking is responsible for 7.8% of the total burden of disease in Australia and results in approximately 15,500 deaths per year¹. The cost of smoking to the community is $31.5 billion per year². Life-long smokers have a 50% chance of dying from a tobacco-related disease, and half of these deaths will occur in middle age (25–54 years)^{3, 4}.

Quitting achieves immediate and long-term benefits. Everyone who smokes can benefit from quitting — the sooner the better. Quitting before the age of 30 years removes almost all of the excess risk associated with smoking; quitting before the age of 50 years halves the risk of smoking-related death⁴.

Have you identified all the smokers among your patients?

Eighteen per cent of males and 15.2% of females smoke daily⁵. At any time, just over half of these smokers are seriously thinking about quitting within the next six months⁶. Nearly two-thirds have tried to quit during the past five years⁷.

Many smokers are pessimistic about their ability to quit⁸ and are often reluctant to ask for help^{9, 10} or use strategies known to be effective in assisting cessation^{7, 11}. However, the trend towards a smoke-free lifestyle is gaining momentum: the number of Australians who have quit smoking now exceeds the number of smokers¹².

Smoking facts

Tobacco smoke contains about 4000 chemicals, including known carcinogens (e.g. nitrosamines, toluidine, nickel, benzopyrene, cadmium, polonium 210), carbon monoxide, hydrogen cyanide, various nitrogen oxides and tar. Top of page

Can general practice make a difference?

The unaided quit rate is 3–5% in a 12 month period^{13, 14}. With assistance, the chance of successfully quitting is 5–7 times higher in people who receive^{3, 15}:

• brief, clear, personalised and non-judgemental advice on quitting AND
• assistance with dealing with nicotine dependence (e.g. medication for managing nicotine withdrawal) AND
• referral to Quitline active call-back program (available in all states).

There is good evidence that GPs can assist smokers to quit^12,16,17.

Additional primary care-based intervention strategies to assist smokers in their attempts to quit include:

• understanding and addressing barriers e.g. withdrawal¹⁸, weight gain¹⁹, dealing with stress^{3, 20}
• helping patients to understand and strengthen their motivation and confidence to quit^{3, 21}.

Challenges to quitting include²²:

• lack of recognition and appropriate management of nicotine dependence
• smokers' reticence to quit without assistance^{7, 11} coupled with their reluctance to use known effective strategies; e.g. Quitline (only 5–10% of smokers call the Quitline²³, less than a third use some form of medication to help with nicotine dependence^{7, 11}).

Cutting down vs cold turkey

Most smokers are advised to go 'cold turkey' rather than gradually reduce before quitting. A recent systematic review found no trials which reported the long-term effects on health of cutting down, and concluded that 'it remains uncertain how much health benefit there is from cutting down'²⁴. However, most smokers would prefer to reduce before quitting^{25, 26}. One suggested approach is to advise smokers to set a quit day 3–4 weeks down the track and to reduce by, say, 50% of their cigarette intake²⁷. Top of page

Figure 1: Reality pyramid levels of intervention²⁷

GP time	Estimated abstinence rate
Intensive (>10 minutes)	22.1%
Moderate (3-10 minutes)	16.0%
Brief (<3 minutes)	13.4%
Supportive organisational infrastructure (nil GP time)	6.4%

Top of page

The value of a 1–3 minute approach

The reality pyramid symbolises a series of sequential steps that the GP can take^{17, 26, 28}. As the pyramid is ascended, the intensity or level of the GP (or practice nurse) offerings increases. The segmentation into time intervals assists the GPs (or practice nurse) in choosing what to offer if they had more time in a consultation. Effective interventions are reframed in terms of the amount of time required to provide them to patients. The ascending layers of the pyramid provide some guidance as to which activities are more worthwhile in a given amount of time. The base of the pyramid represents the impact of a supportive organisational infrastructure that does not involve GP consultation time.

Spending 1–3 minutes on smoking cessation routinely will yield a quitter for every 15–20 minutes spent. Spending more time routinely (e.g. 10 minutes or more) yields a quitter every 45 minutes^{3, 26}. The yield is lower for two reasons:

• more smokers can be counselled if the routine approach involves only 1–3 minutes
• the quit rate does not improve linearly with increasing time spent counselling²⁹.

Recommended reading

• Litt JC. Smoking and GPs: time to cough up: successful interventions in general practice. Aust Fam Phys; 2005; 34(6):425–9.
• Zwar N. Smoking cessation — what works? Aust Fam Phys; 2008; 37(1–2):10–14.
• Zwar N, Richmond R, Borland R, Peters M, Stillman S, Litt J, Bell J, Caldwell B. Smoking cessation pharmacotherapy: an update for health professionals. Royal Australian College of General Practitioners; Melbourne: 2007.

Useful resources

• Smoking cessation guidelines for Australian general practice www.racgp.org.au/smoking/1a
• Smoking cessation pharmacotherapy an update for health professionals www.racgp.org.au
• www.quitnow.info.au Top of page

References

See www.health.gov.au/lifescripts

¹ See national smoking cessation guidelines.
² Note contraindications, adverse effects and drug interactions.
* References in this section are listed in risk factor area evidence references from the practice manual.

Page last reviewed: 18 March 2011