7. Delivering cessation advice

1. 7. Delivering cessation advice Royal College of Physicians of London Tobacco Advisory Group

2. Doctors relevance to smoking cessation • Regular contact and opportunities for intervening • The doctor knows patient’s background • In a consultation the patient is more receptive to advice • The doctor is seen as a credible authority on health matters • Patient’s presented illness may be smoking related • Doctor has options for referral • Even a very brief intervention is effective and cost-effective

3. Why does it matter in medical training • The most vital preventative intervention – though often overlooked • Tobacco dependence not properly characterised as a disease • Dealing with smoking can be a cause of conflict if handled badly • Doctors often unsure what to do • In 1997, only 27% medical students believed that they had sufficient knowledge of smoking cessation techniques.

4. What can/should doctors and other health professionals do? • Follow best practice, make sure you meet the minimum standard for smoking cessation in individual patient contacts • Support and advocate measures to ensure that systematic cessation support is available in your clinical setting • Support broader tobacco control measures • Set an example

5. Thorax guidelines • Primary healthcare teams • Hospitals and community trusts • Specialist smoking cessation clinics • Health care purchasers • Pharmacotherapies Raw M, McNeill A, West R. Smoking cessation guidelines for health professionals. A guide to effective smoking cessation interventions for the health care system. Thorax 1998;53 Suppl 5 Pt 1:S1-19. & Update in Thorax 2000 55: 987-999

6. Five A’s of smoking cessation • Ask about tobacco use • Advise to quit • Assess willingness to make an attempt • Assist in quit attempt • Arrange follow up should be a routine component of all health service delivery

7. 1. Ask • Establish smoking status • smoker, • non-smoker, or • recent ex-smoker, • Record status in notes • Establish interest in stopping • “How do you feel about your smoking?” • “Have you ever tried to stop?” • “Are you interested at all in stopping now”?

8. 2. Advise • Explain the value of stopping and the risks to health of continuing • Personalized, taking account of: • Existing conditions or family history • Early signs of disease • Impact on others – including children • Financial consequences

9. 3. Assess • Establish whether the patient is ready to make a quit attempt • If the person is ready, ask him/her to set a quit date

10. 3. Assist Help should be offered to those who want to quit • Set a date and plan for it • Avoid smoky situations (pub etc) • Involve partner, friends, family • Review past experience – what went wrong? • Refer on for more counselling – specialist service? • Prescribe NRT or bupropion • Call help lines (0800 1690169 or 0800 002200)

11. 4. Arrange Arrange follow up visits

12. Minimumguidance • Ask • Refer to specialist services • If patient can’t be referred, prescribe & follow-up

15. Stages of readiness to change Smoker Non Smoker Relapse Notready40% Maintenance Ready20% Unsure 40%

16. Interactive examples • Role play • Pros and cons • High risk situations • Case study

17. Arguments for quitting • What arguments are available to put to smokers? • How to personalise… • What arguments might smokers use against quitting? • How to respond… • (see notes for suggestions)

18. Role play patient • You are a 50 year old mechanic who has smoked twenty cigarettes a day since the age of thirty and have gone to see the doctor with chest pains. If the doctor asks for more information you could add that you have a recurring cough. It is up to you to decide if you are interested in stopping smoking.

19. Role play doctor • Doctor: Assuming that you have identified the patient as a smoker, • Take a smoking history from the patient • Ask the key question “how do you feel about your smoking?” in order to establish how ready the smoker is to stop. • Ask the patient what stage he/she thinks that they are in ready, unsure or not ready. • The doctor should try and work out how ready the patient is to stop smoking using the readiness to change model.

20. Role play observer • Observer: Having viewed the role play ask the patient how he/she felt about being the patient. You might then ask the doctor if he/she felt that the patient was ready to change stages of readiness. Comment on the doctors choice of stage allocation for the patient.

21. Case studiesIn the following: 1.What were the factors that precipitated relapse to smoking and why did it occur? 2.What was the effect of stress, social pressure or relapse to smoking etc? 3.How would you advise the person who relapsed to approach it the next time that relapse occurs, and what should be done?

22. Anna is a 36 year old lawyer. She decided to cut down on both smoking and drinking last year as she felt that indulging in both excessively was affecting her work. Her decision to quit smoking came after her long-term partner threatened to move out if she continued. Since then Anna has been able to refrain from drinking but as a result of a heavy workload has resumed smoking. In a visit to your surgery she explains that she often finds that smoking helps her to cope during a stressful case. In addition, many of her colleagues smoke when they socialise as a group and it helps her to fit in especially as she does not drink much alcohol any more. Anna’s partner is repulsed by the smell of smoke and often tells her that he finds it disgusting. He also vocalises his worries about her health. Despite this, Anna continues to smoke over 30 cigarettes a day and feels weak as a consequence.

23. Bob is a 24 year old journalist who has been smoking since he was 15. He has relapsed again for the fourth time after quitting for a month. Bob would like to give up smoking because he is aware of the health implications but finds that he can not cope with the cravings. Bob lives in a shared flat with two other smokers and he enjoys getting back from work and consuming a bottle of wine and a few cigarettes with his flatmates as it helps him to unwind. He generally smokes five cigarettes a day and mainly after work. However, he smokes more at the weekend when he goes out.

24. Tom is a 39 year old estate agent. Last year he stopped smoking at the same time as he stopped drinking which was after a series of drunken disorderly charges and suspension from work. He has been able to retain his sobriety until now when he comes to see you at your clinic. He states that he is bored and depressed as he has nothing to do. When he went to visit a friend who was also out of work he started to smoke again. He is ashamed when his son lectures him to stop smoking yet is now smoking 40 cigarettes a day and feels as though he is back to square one.

25. Janine is a nanny and a lone parent with two children aged 2 and 9. Janine smokes around 15 cigarettes a day. Although she stopped smoking during pregnancy, she has resumed smoking again because she feels as though it one of the few things in life left that she does for herself. She particularly enjoys a cigarette with a cup of coffee and after a meal. However, she is becoming increasingly worried about the health effects of passive smoking on her children, one of which is asthmatic.

26. High risk situations • Write down what you think are four high risk situations whereby a person who has quit smoking might relapse. • What could be done to help the patient in these situations? 1 For example: during a coffee break at work 2 3 4

27. Information sources • NHS helpline: 0800 169 0 169 • Websites: • www.ash.org.uk • www.quit.org.uk • http://www.thetimeisright.co.uk/ • http://www.givingupsmoking.co.uk/

28. References and further information References with active links and background information for this presentation is available at http://www.ash.org.uk/?rcp-links