The patient who tries to stop smoking but keeps failing
Harold Fanshaw, 61, attends to request help with stopping smoking. He suffers from ischaemic heart disease and required bypass surgery six months ago. He has been offered advice on numerous occasions and has been prescribed bupropion tablets, nicotine replacement patches and nicotine inhalators by a specialist smoking cessation clinic and by the practice nurse, all within the past 12 months. Dr Richard Stokell advises.
How does this request make you feel?
This request may make you feel frustrated. Should this patient be allowed to go on consuming finite health resources for a self-inflicted condition? If treatment hasn't worked on previous occasions why should it work now, especially as he is likely to have received a package of education and support from both the specialist clinic and the practice nurse?
However, we need to analyse these feelings a bit more before reflecting them back to the patient to avoid being unnecessarily judgmental.
What can we expect from interventions?
The usual rules on changing behaviour apply. We should expect people to need a number of attempts to succeed in quitting. Simply advising cessation is likely to lead to 5 per cent success at one year. Nicotine replacement plus advice will achieve 10 per cent and nicotine replacement plus an ongoing package of support may lead to 15 per cent. Bupropion tablets appear to achieve slightly better success rates, but this has yet to be fully established.
Is this worth it if success rates are so low?
Either treatment is considered to be a highly cost-effective intervention. Although about 17 treatments are needed to produce one extra non-smoker, the cost per life saved compares favourably with most other medical treatments. But our expectation has to be that we will see the majority of patients again.
How should we approach this patient?
Our aim is to maximise the likelihood of success for this patient. We need to look at the motivating factors for him. Ask questions such as: 'Why do you want to stop smoking now?', 'How long did you manage to stop for last time?', 'What prompted you to restart?', 'How did you feel when you started smoking again?'.
This will identify barriers to cessation and may help identify times when the patient is most vulnerable. It may also become clear that this isn't the right time to try again. Spur-of-the-moment decisions or undue pressure from the cardiac surgeon or relatives would prompt me to discuss timing.
Choose a date far enough in advance to focus the patient on the task ahead. This patient also has a lot of experience of smoking cessation. Has he suffered withdrawal symptoms when trying to give up without treatment and when prescribed nicotine replacement or bupropion? Ask him: 'What do you expect to happen when you try again?'
What other factors need to be considered?
The physical, psychological and social situation need to be considered. The presence of a painful and limiting condition, depression or anxiety, or the stresses of being a full-time carer, for example, will all have an effect on the outcome. Treatment for depression or support for a carer may be as effective as our smoking cessation prescription.
How do we prescribe for this patient?
We have several options. We may refer to smoking cessation clinics, either within the practice or outside, or decide to treat the patient ourselves. This option requires close follow-up but may build on the education and support the patient has already received.
I would prescribe weekly but see the patient fortnightly using post-dated prescriptions. I would leave the choice of nicotine replacement, and its route of administration, or bupropion up to the patient. You need to check carefully for contraindications to bupropion.
Would you limit the number of times they could come back to try again?
These patients need to be reassessed on each presentation. There is no specific limit to the number of courses but each relapse should lead to re-evaluation before deciding on further treatment. NICE recommends that, if an attempt to stop smoking is unsuccessful, the NHS will not normally fund another within six months.
lExpect most patients to relapse after smoking cessation interventions
lNRT and bupropion are highly cost-effective health interventions
lPatients should learn something from each attempt at stopping
can be used next time
Richard Stokell is a GP trainer in Birkenhead, Merseyside