Engaging primary care in smoking cessation

1
Engaging primary carein smoking cessation

• Dr Alex Bobak
• GPSI (GP with a Special Interest) in Smoking
  Cessation Wandsworth, South West London

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GPs The key to raising PCT quit rates

• Smokers see their GP about 5 times per year

• GPs are paid to know who smokes and give advice

• GPs are best placed for opportunistic
  intervention and personalised advice1

• Patients want GPs help to stop smoking2

• Great potential for GPs to increase PCT quit
  rates

1. Parrott et al., 1998. 2. Kviz et al., 1997.
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Great Potential

• GPs are the biggest source of referrals to the
  NHS stop smoking services
• But they typically only refer a fraction of their
  smokers
• And they often give poor advice on how to stop
• Why is this?
• Attitudes
• Training

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GP attitudes to Smoking Cessation

• 93 believe that helping a patient stop smoking
  is the best thing we can do for their health

• BUT.
• 63 did not have time to offer treatments
• 61 thought it was ineffective
• 40 felt they lacked skills
• 23 not their job

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GP training in smoking cessation

• Most GPs think they have a reasonable
  understanding about smoking cessation BUT THEY DO
  NOT!!!!

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GP training in smoking cessation

• Most GPs think they have a reasonable
  understanding about smoking cessation BUT THEY DO
  NOT!!!!
• No training as medical students

7
GP training in smoking cessation

• Most GPs think they have a reasonable
  understanding about smoking cessation BUT THEY DO
  NOT!!!!
• No training as medical students
• No training as junior doctors

8
GP training in smoking cessation

• Most GPs think they have a reasonable
  understanding about smoking cessation BUT THEY DO
  NOT!!!!
• No training as medical students
• No training as junior doctors
• No training as GP trainees

9
GP training in smoking cessation

• Most GPs think they have a reasonable
  understanding about smoking cessation BUT THEY DO
  NOT!!!!
• No training as medical students
• No training as junior doctors
• No training as GP trainees
• No training as GPs

10
GP training in smoking cessation

• Most GPs think they have a reasonable
  understanding about smoking cessation BUT THEY DO
  NOT!!!!
• No training as medical students
• No training as junior doctors
• No training as GP trainees
• No training as GPs
• Views on smoking cessation built on everyday
  experience, not evidence eg smoking is a
  lifestyle choice not a disease

11
GP training in smoking cessation

• Most GPs think they have a reasonable
  understanding about smoking cessation BUT THEY DO
  NOT!!!!
• No training as medical students
• No training as junior doctors
• No training as GP trainees
• No training as GPs
• Views on smoking cessation built on everyday
  experience, not evidence eg smoking is a
  lifestyle choice not a disease
• Myths about smoking are common among GPs

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GPs Knowledge on Nicotine

• Incorrect beliefs about nicotine in cigarettes
• 51 think it causes cardiovascular disease
• 49 think it causes strokes
• 41 think it causes lung cancer

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GPs Knowledge on Nicotine

• Incorrect beliefs about nicotine in cigarettes
• 51 think it causes cardiovascular disease
• 49 think it causes strokes
• 41 think it causes lung cancer
• 6 think NRT is as harmful as cigarettes!

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QOF (Quality and Outcomes Framework)

• Big financial incentive to engage GPs in smoking
  cessation or at least provide brief interventions
• But has not improved smoking prevalence in
  practices
• 2 aspects to QOF for smoking cessation
• get smoking status
• give smoking advice
• But no guidance as to what is good advice...

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VIDEO CLIP OF BAD AND GOOD GP BRIEF
INTERVENTIONS
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30 Second Approach Questions

• Do you smoke? or Are you still smoking? (QOF
  POINT)
• Would you like to stop?
• Would you like help to stop because the best
  proven way is with support from a trained stop
  smoking adviser plus treatment? (QOF POINT)
• Direct to LSSS adviser

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Bad intervention

• Confrontational put the smoker off the GP let
  alone a quit
• Told the smoker to stop rather than how to stop
• It was negative and didnt offer anything new
• Much longer - appointment might overrun
• GP frustrated and smoker irritated
•  
• Put GP and smoker off helping and being helped

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30 second approach

• Shorter and so easier to use routinely
• Positive and so kept the smoker engaged
•  
• New ideas on how to stop not old arguments on why
• Evidence based we know that a combination of
  support and treatment does greatly increase long
  term quit rates
• Gives the GP QOF with conscience!

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What do many GPs do now?

• Practice non evidence based smoking cessation
• Offer brief intervention of variable quality
• Prescribe inappropriately
• Give poor advice on treatments
• Offer inadequate support
• Have poor understanding of their local stop
  smoking service

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What can be done?

• Educate GPs in the why and how of brief
  interventions
• Educate GP staff in brief interventions and some
  to become stop smoking advisers
• Engage practices in delivering good quality
  smoking cessation

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Educating GPs

• GPs do not willingly go to meetings on smoking
  cessation!!

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Educating GPs

• GPs do not willingly go to meetings on smoking
  cessation!!
• Best to slot the training session in to an
  established meeting such as
• A meeting on a smoking related topic eg COPD,
  CHD, stroke, asthma, diabetes etc
• A PCT protected learning time meeting
• Regular postgraduate GP meetings (often at
  lunchtime at the local PGMEC or large GP
  practices)
• GP trainee meetings via the local GP training
  scheme

23
Educating GPs

• GPs do not willingly go to meetings on smoking
  cessation!!
• Best to slot the training session in to an
  established meeting such as
• A meeting on a smoking related topic eg COPD,
  CHD, stroke, asthma, diabetes etc
• A PCT protected learning time meeting
• Regular postgraduate GP meetings (often at
  lunchtime at the local PGMEC or large GP
  practices)
• GP trainee meetings via the local GP training
  scheme
• Think what a GP needs to know- not the same as an
  adviser

24
Educating GPs

• GPs do not willingly go to meetings on smoking
  cessation!!
• Best to slot the training session in to an
  established meeting such as
• A meeting on a smoking related topic eg COPD,
  CHD, stroke, asthma, diabetes etc
• A PCT protected learning time meeting
• Regular postgraduate GP meetings (often at
  lunchtime at the local PGMEC or large GP
  practices)
• GP trainee meetings via the local GP training
  scheme
• Think what a GP needs to know- not the same as an
  adviser
• Concentrate on brief intervention training

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Educating GP staff

• Practice Nurses AND Health Care Assistants
• Much more willing
• Avoid delegation if possible
• Existing workload
• Motivation
• Good way to engage a practice

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How to engage a practice

• Make a financial case first
• Make a health case second!
• Emphasise no extra work for the GP
• Emphasise patient satisfaction

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Financial Case

• To the practice manager
• Explain HCA can deliver smoking cessation after a
  free two day course
• Doesnt have to be Dr or Practice Nurse
• Demonstrate practice profit if possible
• QOF (not just smoking points)
• LESs (Locally Enhanced Services)
• Data capture and other projects to fill DNAs

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Health Case

• Take care with the Duty of care argument!
• Talk about NNTs in General Practice
• NNTs are the Number (of patients) Needed to Treat
  to make or prevent a health outcome
• You can compare the benefits of smoking cessation
  compared with other interventions in general
  practice

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Comparative NNTs
1. Bandolier 2. Gates, Am Fam Phys 2001.
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Numbers Needed to Treat (NNT) to Obtain 1
Long-Term Quitter?

• Brief advice (lt5 mins) 40(1)
• Adding medication to behavioural support..
• NRT 20(2)
• Bupropion 15(2)

• Varenicline 8(2)

1. West (2006) 2. Cochrane Review. (2007)
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Numbers Needed to Treat (NNT) to Prevent a
Premature Death?

• Brief advice (lt5 mins) 80
• Adding medication to behavioural support..
• NRT 40
• Bupropion 30
• Varenicline 16

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Summary

• Great potential for referrals from GPs
• Understand GP attitudes and knowledge (or not!)
  of smoking cessation
• Engage practice staff
• Educate where you can
• Focus on brief interventions..