Stop patients smoking

Now more than ever, the Government is adamant about helping the nation to stop smoking. GPs play a very important role in assisting in this process, as Dr Rob Hicks explains

Sometimes it is like banging your head against a brick wall. Everyone knows the damage smoking causes to their health, yet people still choose to take that little comfort stick and fill themselves with chemicals. Even though in 1995 over 120,000 deaths were caused by smoking (for example, cancer, circulatory disease, and respiratory disease)¹, our contribution as GPs in helping people to pack it in has been shown to be of use.

Reasons for smoking

GPs who are smokers or have smoked in the past, probably understand why someone smokes and so have the advantage when it comes to trying to help someone quit. Those GPs who have never smoked, first need to understand why people choose to take up and continue with the habit. Banging on about the health benefitsÑhealthy heart, lungs, and skin; avoiding cancers; firmer erections and better sperm; healthier pregnancies, babies, and children; and so onÑis only part of the equation. If it was the only factor for smokers then they would stop. But it is not. The number of children and young people starting to smoke is increasing² and it is in teenage years when 82 per cent of smokers start. The influence of peers and family members is a major factor why people start smoking³. Also the glamorous image portrayed in the movies; pop idols wearing the cigarette as a fashion accessory; teenage rebellion or exploration; the reasons are many. Nicotine is addictive and once established people crave either the stimulant effects of a short drag or the relaxant effects of a deep inhalation. If it is a time of great change or stress in other parts of their life then adding another to the list by asking them to give up smoking may not be appropriate.

Helping patients quit

At certain times in a smoker's life, however, the balance of this equation swings towards stopping smoking. Often it is the illness or death of someone close, or thoughts of starting a family that are the triggers. When the balance is weighted in favour of giving up smoking, when the person is ready to stop, that is the time for the GP to strike. Three minutes of a GPÕs time increases the number who stay abstinent for six months or more by two per cent. Give up to ten minutes of our time and it is three per cent who stay off the weed⁴. During this counselling, the benefits of giving up should be reemphasised. Giving up smoking needs help and many studies have demonstrated how on-going support is the key to successful abstinence⁵. This should be positive and smokers should be reassured that if they do not succeed first time (and many do not) that they should not feel guilty and should come back for help. It may be the GP or practice nurse who provides this but increasing time constraints usually means this is difficult.

Clinics and support groups. Some practices run smoking cessation clinics and many put patients in contact with support groups. National organisations such as 'Quitline' in England and 'Smokeline' in Scotland provide very helpful advice and support to patients. Some of the manufacturers of nicotine replacement therapy run support programmes and if these are available patients should be encouraged to make use of them.

Treatment

Most often it is fear of withdrawal symptoms that has an over-whelming negative effect. Thoughts of becoming a tense, aggressive, nervous wreck, may be based on personal experience from past attempts or that of friends. This needs to be addressed by explaining how withdrawal symptoms begin within a few hours of stopping, peak within a few days, and usually only last around four weeks.

Nicotine replacement therapy (NRT) has been shown to be significantly more effective than placebo in helping people cope⁶. As a rough guide it is said to double a person's chances of remaining abstinent when combined with brief (up to ten minutes) advice. There are a wide variety of NRTs available: gum, patches, nasal spray, inhalators, sublingual tablets--providing the opportunity to choose one that best suits the needs of the patient and is acceptable to them. In general, GPs are being advised not to prescribe NRT on an NHS prescription because those few that remain on the NHS list are likely to be black-listed eventually, as has been the case with the others. At present, the only NRT products available on prescription include Nicorette Microtab, Nicorette Inhalator and Niquitin CQ. Costs very much depend on dose, frequency of use and pharmacy prices. As a rough guide, a three-month reducing course of Nicorette patches, starting at the largest dose, costs £182.76. A ten-week reducing course of Niquitin CQ costs about £199.50. Put into context, if a pack of 20 cigarettes costs about £3.50, then a smoker who consumes one pack per day, will spend about £250 for ten weeks supply of cigarettes. Patients need to learn ways of coping with any stress and how to deal with the craving for 'just one more', particularly in situations that may precipitate relapse such as the pub or around smoking friends. Relaxation techniques, avoidance of situations where temptation may win over, or having something to occupy tempted fingers helps many.

Complementary therapies. Anecdotally, people have found benefit from complementary therapies, notably acupuncture and hypnosis, in giving up and staying abstinent. Provided the therapy selected offers the possibility of cessation without causing harm, then it is reasonable to support someone who wishes to try this way remembering that motivation and support are the key factors in successful smoking cessation. It has recently been suggested that the herb St John's Wort may help people quit smoking by removing the craving sensation that people experience. A clinical trial exploring this theory is currently underway in London.

Conclusion

It is clear that the single most important health intervention for anyone is not to smoke. In general practice it is easy to become disheartened and to think, 'what is the point' when our efforts appear to get lost or ignored by our patients. However, it is important to remember that as GPs we are one part of a successful smoking cessation package, a small part but a vital one. As with any other multi-faceted project, leave one part out and there is a good chance it will not work

Rob Hicks is a general practitioner in London

References

1 Callum C. The UK Smoking Epidemic: Deaths in 1995. London: Health Education Authority, 1998
2 Department of Health. Smoking Kills. A White Paper on Tobacco. London: The Stationary Office, 1998
3 Tyas SL, Pederson LL. Psychosocial factors related to adolescent smoking: a critical review of the literature. Tob Control 1998; 7: 409-20
4 Raw M, McNeill A, West R. Smoking cessation guidelines for health professionals. Thorax 1998; 53 (Suppl 5, part 1): S1-S19
5 The smoking cessation clinical practice guideline panel and staff. The Agency for Health Care Policy and Research smoking clinical practice guideline. JAMA 1996; 275: 1270-80
6 Silagy C, Mant D, et al. Nicotine replacement therapy for smoking cessation (Cochrane review). In: The Cochrane Library Issue 2. Oxford, Update Software, 1998, Updated quarterly