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At the heart of general practice since 1960

Smoking cessation

As the English smoking ban looms, Dr John Havard offers advice on helping patients quit

As the English smoking ban looms, Dr John Havard offers advice on helping patients quit

1 Ask if they want to quit. Opportunistic questioning in consultations is vital and may lead to a patient being motivated to give up. Confirmed smokers will often assert that they are not worried by health, wealth or social stigma issues – but they usually are. Challenge them gently by asking if they wish they had never smoked that first cigarette and if they encourage their children to smoke? A few seconds of introspection usually brings the patient on side but this is a precious moment and an opportunity to really engage and cement a resolution to quit. Comments such as 'We all play tricks on ourselves' are often helpful catalysts to the decision to give up.

2 Why do they smoke? There is a balance between the physical addiction to nicotine, the habitand the fear of not having the next cigarette.It is important to establish the type of smoker that the patient is in order to help themmost effectively.

3 Which method of smoking cessation is likely to be most helpful? This is a time for the nurse or GP to establish the smoking history and the details of previous quit attempts. Previous failures are analysed so that they feed intothe quit strategy.

4 Medical history. We need to document any potential contraindications to pharmaceutical products. Certain neurological conditions exclude the use of bupropion. Contact dermatitis is more likely in sensitive patients, making NRT patches less attractive.

5 Empowerment. Give patients the sense of directing their own outcome, not of being dictated to. With mutual consent we offer the support of other patients who are successful quitters. Of course, patients often have friends or family who have given up, which is why they are keen to quit in the first place.

6 Medical observations. We use a carbon monoxide meter to show patients what is going on in their lungs. The abnormal reading is discussed and set in concrete by a comparative breath test by the nurse or GP. Blood pressure and pulse are also recorded and sometimes tactful observations are made about actualor potential damage to teeth, skin and hair as further ways of encouraging smokers to quit.

7 Support regular contact. Patients need to decide if they would like to quit in a group or in one-to-one consultations. Ongoing support and contact are crucial and down to patient choice. GP or nurse visits can be supplemented with phone, email or text messaging. We tell patients that we want to give them every opportunity to succeed in giving up smoking and will adapt any method to their liking.

8 Give information and involve the family. There is a mass of published material and we ask patients to keep what they find useful. Involving the family, especially children, is important as young children are usually very supportive of parental efforts to give up and will want to help as much as they can. Choosing the quit date is something all the family need to be involved in.

9 Reward. Patients need to focus on a reward and the pack-a-day smoker is going to be saving £150 per month – which, when used to pay for something they wouldn't normally buy, such as a holiday, helps measure the value of the reward. Many smokers are really proud of giving up and one told us that she felt she deserved a medal. We then decided to produce a badge which we now give to all our quitters which is meant to show, in a modest way, how our practice values their real achievement in giving up.

10 Follow-up is crucial for support and validation. All those who attempt to quit must know they will be followed up by the practice even if they fail to attend the clinic. Everyone attending WeightWatchers knows about the weekly weigh-in and this helps their resolve during the week.

It is imperative that 'failures' do not get disheartened and we tell them that we see it as our failure in not motivating them adequately to succeed.It takes three weeks to develop a nicotine addiction and, without NRT, it takes three weeks to get over it.

The psychological factors are much more complex and shrouded in illusions. Smokers feel they are unable to relax, concentrate or even enjoy life without a cigarette. The tobacco industry has created this image but the truth is that cigarettes actually worsen enjoyment of life.

An addictive enslavement to cigarettes makes smokers continue with a habit that tastes awful, costs a packet and will probably kill them.

Finally, a positive attitude is vital, with the glass being half full not half empty. Many smokers quit easily and on their own and yet often ex-smokers talk about 'surviving' without cigarettes whereas they should be celebrating every new day of enhanced health and wealth.

Dr John Havard is a GP in Saxmundham, Suffolk

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