Smoking cessation guidelines
Aims of the guidelines
Tobacco smoking is responsible for the deaths of approximately 19,000 Australians each year (Ridolfo and Stevenson, 2001). These guidelines aim to assist general practitioners (GPs) and their practice staff to more effectively identify smokers and assist them to stop smoking. The guidelines are an adaptation of the "5As" for brief intervention that are the basis of the United States Clinical Practice Guideline Treating Tobacco Use and Dependence (Fiore et al, 2000). The "5As" approach was a development of the 4As approach of the United Kingdom guidelines (Raw et al, 1998). The 5As approach has also been used as the basis of revised guidelines for smoking cessation in New Zealand (National Health Committee, 2002). The Royal Australian College of General Practitioners has published Guidelines for preventive activities in general practice (RACGP, 2002) which include brief guidelines for smoking cessation. These smoking cessation guidelines for Australian general practice have been developed from a review of all of these materials plus guidelines produced for special groups.
These guidelines also build on work conducted in Australia on assisting smoking cessation and on other risk factors for preventable disease. The Smokescreen Program was the first program to apply the Stage of Change Model (Prochaska and DiClemente, 1983) in the general practice setting. Developed by Professor Robyn Richmond and colleagues, the Smokescreen Program (Richmond et al, 1991) acknowledges that the smoker's own motivation to stop is a key issue and advice is provided based on the smoker's readiness to quit. The Smokescreen Program has been extensively studied in general practice (Richmond and Anderson 1994; Richmond 1996; Richmond, 1996; Richmond and Mendelsohn 1998). In a study of the efficacy of the Smokescreen Program involving three GPs and 200 smokers there was an abstinence rate of 36% in intervention group and 8% in the non-intervention control group at three years follow-up (Richmond et al, 1986). A larger study involving 26 GPs and 450 smokers showed that those offered counselling using the Smokescreen approach and nicotine replacement therapy had an abstinence rate of 19% after one year compared to 12% abstinence in those offered the nicotine gum and minimal advice (Richmond et al, 1993). Smokescreen was widely disseminated to GPs in Australia and New Zealand in the 1990s through workshops organised in collaboration with Divisions of General Practice and Independent Practitioners Associations. The guideline development process provides the opportunity to produce updated resources for general practitioners that build on the experience of the Smokescreen Program and explicitly incorporate the 5As approach.
These guidelines link smoking cessation advice in general practice to the National Tobacco Campaign and to the materials and support services provided through the Quitlines operating in each state and territory. These smoking cessation guidelines are consistent with the approach to risk factor identification and intervention of the Smoking, Nutrition, Alcohol and Physical Activity (SNAP) Framework suggested by the Joint Advisory Group on General Practice and Population Health (June 2001). The SNAP framework and these guidelines both recognise that, though evidence of effectiveness of brief advice and other strategies for smoking cessation such as pharmacotherapy has been known for some years, the implementation of these strategies has been variable and not well supported. The RACGP publication Putting prevention into practice (RACGP, 1998) has sought to assist GPs to create systems in their practice to support preventive activities.
The evidence base that underpins these guidelines has been drawn from the National Tobacco Strategy publication Smoking cessation interventions: review of evidence and implications for best practice in health care settings (Miller, 2001). The guidelines were developed by a project group from University of New South Wales School of Public Health and Community Medicine, The Cancer Council Victoria and General Practice Education Australia. An extensive process of stakeholder consultation has also informed the development. This process led to Flinders University's involvement in the project group, representing the GPs assisting smokers program (GASP).
