7.10 Role of general practice and other health professional settings
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About 85% of Australians visit a general practitioner (GP) at least once a year.236 This provides an excellent opportunity for promoting smoking cessation. GPs are seen as credible and authoritative on health issues, and their advice is seen as appropriate and acceptable.237, 238 There is also good evidence that even very brief intervention can be effective in prompting quitting.239, 240
Time pressure makes it realistic for most GPs to spend only limited time with most smokers (i.e. a few minutes), which can be incorporated into routine consultations. One widely researched approach that enables this is called the 5As and has been the basis for recommendations for best practice in the United States56, 57, 108, United Kingdom241 and New Zealand.242 The Smoking Cessation Guidelines for Australian General Practice based on this approach were developed after extensive reviews of the evidence.47, 48, 243
The recommended procedure is:
1. Ask. The first step in helping smokers to quit is to identify them. A system for recording the current and previous smoking status of every client (except children) can help quitting by itself, because it signals to smokers that it is important, and almost doubles the rate of clinician intervention, and results in higher cessation. The system used needs to be integrated into the usual record keeping of the practice.
2. Assess. Assessing a smoker's readiness to change is important. The stages described in the section on the process of quitting (7.3) provide one framework. Asking 'How do you feel about your smoking at the moment?' will often be enough to begin such an assessment. For those considering quitting, it is also important to assess level of nicotine dependence. The most widely used approach is the Fagerstrom Test for Nicotine Dependence in either its full form or one of several shorter versions.
3. Advise. All smokers should be advised of the importance of quitting in a way that is clear, unambiguous, supportive and non-confrontational. For example 'Stopping smoking is the most important thing you can do to protect your health now and in the future.' GPs can link this advice to the individual health concerns of the client.
4. Assist. The assistance provided should be related to the smoker's readiness to change. For example concrete help to smokers interested in quitting might involve assistance by the GP if time and expertise permit, by other trained practice staff, or by referral to specialised assistance from the Quitline.
5. Arrange follow-up. Following up those who commit to making a quit attempt can help to keep them on track. A phone call or appointment after one week and one month can provide valuable encouragement, advice on relapse prevention, slip ups or other issues encountered. The Quitline provides such ongoing support to all who want it. At future consultations, GPs should congratulate those who successfully quit and encourage those who have relapsed to try again, using the 5As process. For those not ready to quit, the issue of smoking needs to be raised regularly at future consultations.
The guidelines can be easily adapted for use by doctors in other settings such as specialist clinics or hospitals. Other health professions can also use the guidelines. In particular the approach is likely to be useful for:
- Nurses and midwives, whether working in a community setting, hospital, medical or mental health service.
- Dentists and dental hygienists. Smoking is a significant contributor to oral disease.
- Pharmacists and pharmacy assistants. Pharmacies supply cessation products and there are opportunities for providing sound advice and support.
- Drug and alcohol workers. Smoking is much more common among their clients, and contributes to poor health outcomes.
- Psychologists, especially if working in clinical settings.
- Physiotherapists and other allied health professionals.
Health services have traditionally been more oriented to cure rather than prevention, but there are moves to reorient health services more towards prevention and health promotion. Smoking cessation, nutrition, obesity, excess alcohol use and physical activity are increasingly seen as essential targets for GPs, hospital, and community health services as part of efforts to reduce or manage preventable 'lifestyle' health problems.244
Some doctors or other health professionals may have the opportunity to provide more intensive interventions for smokers. There are several effective group and individual programs including Fresh Start (described in more detail below) and Smokescreen.237, 245
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