Supporting a Quit Attempt
Completing the VBA will tell you your patient’s self-reported tobacco status – an important first step.
VBA is our most practical tool to trigger a quit attempt, with structured behavioural support and medical treatment being the best method of quitting and ideally these are provided by stop smoking practitioners. If smokers are unwilling or unable to attend specialist stop smoking services to quit smoking support can be effectively offered by GPs within a series of standard 10-minute appointments. In September 2018, the Royal College of General Practitioners (RCGP) issued practical guidance on the delivery of smoking cessation support by GPs consisting of a pre-quit appointment, subsequent weekly, biweekly then monthly appointments over 2 to 3 months and a final visit. This guidance is available as an online course via the RCGP elearning portal (course name: Essentials of smoking cessation). The core components of the guidance are summarised below:
- Discuss available treatments and prescribe treatment/s for the first 2 weeks
- Agree and record a quit date
- Check breath carbon monoxide if possible
- Arrange a follow up appointment in one week
Subsequent appointments (continue for 8–12 weeks)
- Discuss treatment and progress
- Ideally check CO
- Prescribe further treatment
- Arrange next appointment
- Congratulate success, encourage and advise on avoiding lapses
- Reassure that the ‘door is always open’ if they go back to smoking
As a clinician you will also be treating people for conditions where management of tobacco dependency is part of the therapy pathway and because the impact of continued use is so serious. You may therefore need to gather more information to help co-create a plan with your patient or indeed find yourself holding information that needs further discussion.
- Women booking pregnancy in England are expected to have an exhaled carbon monoxide recording by a relevant healthcare professional regardless of reported smoking status.
- A joint colleges recommendation led by RCPsych recommends people with severe mental illness have an exhaled CO check at their annual physical review and that smoking is considered at each interaction with the health system.
The best way of determining smoking status is to ask people: “Do you smoke?”.
The exhaled carbon monoxide (CO) test detects exposure to CO in the last 12-18 hours. This can be used to assess smoking status AFTER a quit attempt and used prior to a quit attempt as a motivational tool. Higher levels (parts per million) equate with greater inhalation of tobacco smoke assuming the cause is tobacco smoking. It must be noted that the exhaled CO test indicates recent exposure to CO and will not indicate smokeless tobacco use and is not a measure of dependency. In pregnancy, a CO of 3 ppm has been proposed as an appropriate cut-off for referral to stop smoking services.
The cotinine test is more specific for nicotine exposure and ay be useful in the context of infrequent waterpipe use or smokeless tobacco use and can also be collected via a urine sample in the case of children who may be exposed to environmental tobacco smoke. It is not useful for people who use NRT or e-cigarettes and is a laboratory-based test.
Pack years provides a measure of exposure; this calculator also allows the evaluation of cigars, roll-up cigarettes, pipes, tobacco by weight and water pipe use and converts them to pack-year equivalents).
Number of years a person has smoked.
All smokers will benefit from support to quit smoking. The Expert Group advocate that it is important for clinicians to be able to identify those likely to need more intensive interventions to quit. Ways to evaluate level of dependency and indicators suggesting patients may need more intensive support include:
More dependent smokers: Heaviness of smoking index (HSI) provides a score for nicotine dependency:
- Question 1: On the days that you smoke, how soon after you wake up do you have your first cigarette? A. Within 5 minutes (3 points) B. 6–30 minutes (2 points) C. 31–60 minutes (1 point) D. After 60 minutes (0 points)
- Question 2: How many cigarettes do you typically smoke per day? A. 10 or fewer (0 points) B. 11–20 (1 point) C. 21–30 (2 points) D. 31 or more (3 points)
- A patient will have an HSI score of between 0 and 6 with a higher number indicating heavier dependence and thus a need for more intensive behavioural support and treatment. The patient can be informed of this.
For time-pressured clinical environments, the one question that is most helpful in determining a high nicotine addiction is: How soon after waking do you smoke your first cigarette (use tobacco). The sooner the time to first use of tobacco after waking the greater the nicotine addiction. This will impact on the level of treatment and support that you need to recommend to the patient.
- People with severe mental illness
- Those who continue to use tobacco whilst experiencing a severe, life-shortening, disabling or frightening co-morbid problem such as COPD or throat cancer
- Pregnant women
A variety of interventions and support services have been shown to enhance the chances of achieving a successful quit. The National Institute for Care Excellence (NICE) has described those interventions at person, organisation and system level that have a clinical and cost effectiveness evidence base.
Behavioural support combined with either pharmacotherapy (varenicline) or NRT (combination of long-acting and short-acting therapies) are likely to be the most effective approach to support a quit attempt.