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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

7.1 Smoking

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 >80

Smoking status and interest in quitting should be assessed and documented in the medical record for every patient >10 years of age.3,13,60 All patients who smoke, regardless of the amount they smoke, should be offered smoking cessation advice. This should include the following actions:

  • Ask about their interest in quitting (B).
  • Advise to stop smoking (A), agreeing on quit goals and offer pharmacotherapy to all patients smoking more than 10 cigarettes per day unless contraindicated, especially if there is evidence of nicotine dependence (A).
  • Offer referral to a proactive telephone call-back cessation service (eg Quitline 13 7848; A).
  • Follow up to support maintenance and prevent relapse using self-help or pharmacotherapy (A).

To assess nicotine dependence, ask about the:60

  • number of minutes between waking and smoking the first cigarette
  • number of cigarettes smoked a day (there is a high likelihood of nicotine dependence if the person smokes within 30 minutes of waking and smokes more than 10–15 cigarettes a day)
  • type of craving or withdrawal symptoms experienced in previous quit attempts.
Table 7.1.1. Smoking: Identifying risks
Who is at risk?What should be done?How often?
Average risk:
  • Everyone >10 years of age
Ask about quantity and frequency of smoking (I, A). Offer smoking cessation advice, set quit goals, offer pharmacotherapy, referral and follow-up as appropriate (II, A) 60 Opportunistically* (III, C)
High risk of complications:
  • Aboriginal and Torres Strait Islander peoples
  • People with smoking-related disease
Offer smoking cessation advice. Agree on quit goals, offer pharmacotherapy and culturally appropriate referral and support Opportunistically, ideally at every visit* (III, C)
Aboriginal and Torres Strait Islander peoples 61 (II, A)
People with smoking-related disease (I, A)
Patients requiring different interventions to those at average risk
  • People with mental illness
  • People with other drug-related dependencies
Make careful use of pharmacotherapy, because of the significant impact of nicotine and nicotine withdrawal on drug metabolism (I, A)‡ 62

Add mood management to behavioural support in those with current or past depression
Opportunistically, ideally every visit* (III, C)
  • Pregnant women
Offer smoking cessation advice, agree on quit goals, offer referral to a quit program (I, A). Also refer to Chapter 1. Preventive activities prior to pregnancy At each antenatal visit (III, C)
  • Parents of young babies and children
Offer smoking cessation advice. If the parent is unable to quit, advise to:
  • smoke away from children
  • not smoke in confined spaces with children (eg when driving) (I, A)
Opportunistically, ideally every visit* (III, C)
  • Adolescents and young people
Ask about smoking and provide a strong antismoking message (III, C) Opportunistically (III, C) 63
*Refer to Appendix 9. Effect of smoking abstinence on medications in the New Zealand smoking cessation guidelines 2007

†While enquiry about smoking should occur at every opportunity, be aware of patient sensitivity. Non-judgmental enquiry about smoking is associated with greater patient satisfaction 64–66

Implementation

At an individual patient level, GPs and their teams can influence smoking rates by systematically providing opportunistic advice and offering support to all attending patients who smoke.67 Where this is insufficient, other effective treatment strategies include referral to the Quitline,68 pharmacotherapy 69,70 and motivational interviewing.71,72

Tobacco use is most effectively treated with a comprehensive approach involving behavioural support and pharmacotherapy. Combined pharmacotherapy and behavioural support increases the success of smoking cessation.73

Pregnant women find it especially difficult to quit; pregnancy alters nicotine metabolism and heightens withdrawal symptoms and the support from partners is an important element in quitting. Higher smoking rates in disadvantaged individuals reflect greater neighbourhood disadvantage, less social support, greater negative effect and lower self-efficacy.21,28 Removing access barriers and providing incentives to motivate patients to quit may improve quit rates.

Patients should be reviewed within one week and again after one month of stopping smoking in order to help increase the long-term chance of quitting.

There is a lack of consistent, bias-free evidence that acupuncture, acupressure or laser therapy have sustained benefit on smoking cessation for longer than six months.74 There is insufficient evidence that electronic cigarettes(e-cigarettes) help smokers to stop smoking when compared with nicotine patches or placebo.75

The CEITC provides resources and strategies at www.ceitc.org.au

References

  1. Fiore M, Jaen CR, Bake TB, et al. Treating tobacco use and dependence: 2008 Update. Rockville, MD: Department of Health and Human Services, Public Health Service, 2008.
  2. Hung DY, Shelley DR. Multilevel analysis of the chronic care model and the 5A services for treating tobacco use in urban primary care clinics. Health Serv Res 2009;44(1):103–27.
  3. Zhao Y, Condon JR, Guthridge S, You J. Living longer with a greater health burden – Changes in the burden of disease and injury in the Northern Territory Indigenous population between 1994–1998 and 1999–2003. Aust N Z J Public Health 2010;34:S93–S98.
  4. DiGiacomo M, Davidson PM, Abbott PA, Davison J, Moore L, Thompson SC. Smoking cessation in indigenous populations of Australia, New Zealand, Canada, and the United States: Elements of effective interventions. Int J Environ Res Public Health 2011;8(2):388–410.
  5. The Royal Australian College of General Practitioners. Supporting smoking cessation: A guide for health professionals. South Melbourne, Vic: RACGP, 2011.
  6. The Royal Australian College of General Practitioners. Supporting smoking cessation: A guide for health professionals. South Melbourne, Vic: RACGP, 2011.
  7. Carson K, Brinn M, Peters M, Esterman A, Smith B. Interventions for smoking cessation in indigenous populations. Cochrane Database Syst Rev 2012;1:CD009046.
  8. Hartmann-Boyce J, Stead LF, Cahill K, Lancaster T. Efficacy of inteventions to combat tobacco addiction: Cochrane update of 2013 reviews. Addiction 2014;109(9):1414–25.
  9. Stanton A, Grimshaw G. Tobacco cessation interventions for young people. Cochrane Database Syst Rev 2013(8):CD003289.
  10. Solberg L, Boyle R, Davidson G, Magnan S. Patient satisfaction and discussion of smoking cessation during clinical visits. Mayo Clinic Proceedings 2001;76(2):138.
  11. Sciamanna C, Novak S, Houston T, Gramling R, Marcus B. Visit satisfaction and tailored health behavior communications in primary care. Am J Prev Med 2004;26(5):426–30.
  12. Miller WR, Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychother 2009;37(2):129–40.
  13. Stead M, Angus K, Holme I, Cohen D, Tait G. Factors influencing European GPs’ engagement in smoking cessation: A multi-country literature review. Br J Gen Pract 2009;59(566):682–90.
  14. Schuck K, Bricker J, Otten R, Kleinjan M, Brandon T, Engels R. Effectiveness of proactive quitline counselling for smoking parents recruited through primary schools: Results of a randomized controlled trial. Addiction 2014;109(5):830–41.
  15. Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev 2012;11:CD006103.
  16. Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2012;11:CD000146.
  17. Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking cessation interventions: A systematic review and meta-analysis to compare advice to quit and offer of assistance. Addiction 2012;107(6):1066–73.
  18. Lindson-Hawley N, Thompson TP, Begh R. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev 2015;3:CD006936.
  19. Stead LF, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev 2012;10:CD008286.
  20. White A, Rampes H, Liu J, Stead L, Campbell J. Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev 2014;1:CD000009.
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