Best possible advice and support to quit

Morgan Liotta

29/01/2020 1:43:30 PM

New RACGP guidelines are designed to help remove barriers to greater efforts to provide smoking cessation advice.

Hard copy of the smoking cessation guidelines
A number of key evidence-based updates are incorporated in the new guidelines.

Lack of time, lack of confidence in providing useful advice, perception that smoking cessation is ineffective and the patient lacks motivation, reluctance to raise the issue because of perceived patient sensitivity about smoking.
These are the main barriers cited by health professionals on providing smoking cessation advice.
Most of these barriers are based on incorrect assumptions or can be overcome, according to the recently released second edition of the RACGP’s Supporting smoking cessation: A guide for health professionals.
There have been a number of significant developments in the field of smoking cessation since the last update in 2014, including recommendations for the use of combination nicotine replacement therapy (NRT), the use of NRT during pregnancy, nicotine-containing e-cigarettes, and the brief intervention approach.
Providing comprehensive up-to-date guidance for primary healthcare providers to best support patients in quitting smoking, the guidelines also incorporate GRADE – Grading of Recommendations, Assessment, Development and Evaluation – a new approach to assessing clinical evidence and drafting practice recommendations.
The introduction of the three-step brief intervention approach ­– Ask, Advise, Help – developed by Quit Victoria, will arm health professionals with more streamlined advice, and enable them to offer that advice more frequently.
Professor Nick Zwar, Chair of the guidelines’ Expert Advisory Group, told newsGP the three-step model has already been adopted in other countries, including New Zealand and the UK.
‘The idea is to reduce the barrier of time to providing smoking cessation advice, as time is a frequently cited issue,’ he said.
‘GPs and practice nurses can use this approach when they do not have time to provide comprehensive support within the practice.’
Dr Sarah White, Director of Quit Victoria and smoking cessation advisor to Cancer Council Australia, said that the brief intervention model is a major improvement in ensuring people who smoke receive best practice care.
‘Most people who smoke want to quit,’ she said. ‘All health professionals should be asking if their patient smokes, advising them to quit and explaining the best ways to quit.
‘The new RACGP guidelines spell out how every health professional can provide best practice care in any clinical setting.’
The guidelines cover the most effective and legal first-line pharmacotherapy options for smoking cessation. In Australia these include NRT, varenicline and sustained-release preparations of bupropion hydrochloride.
Details are included of the efficacy of evidence-based combination pharmacotherapy, including that bupropion has been shown to be as effective as NRT monotherapy, but evidence from three randomised controlled trials suggests that it is less effective than varenicline.
Smoking cessation for populations with special needs – including women who are pregnant or breastfeeding, people in low socioeconomic areas, people with mental health issues and Aboriginal and Torres Strait Islander peoples – is also a focus area of the guidelines.  
Including combination NRT on the Pharmaceutical Benefits Scheme (PBS) for first-line treatment for smoking cessation would be most beneficial to these populations with special needs that require more support in the smoking cessation journey, according to Professor Zwar.
‘There is evidence from meta-analysis of randomised trials that combination NRT improves quit rates over NRT monotherapy,’ he said.
‘Given the importance of cessation to health and the low cost of NRT, this form of therapy should be available on the PBS.’
The RACGP has also called for greater flexibility in prescribing smoking cessation pharmacotherapy and more affordable options for patients who most need them by introducing PBS-subsidised combination NRT.
Currently only oral forms of NRT – gum and lozenges – are PBS-subsidised.
Although considered a potential second-line option for smoking cessation, the use of nicotine-based e-cigarettes has been ‘cautiously recommended’ by the RACGP and the Expert Advisory Group.
‘Nicotine-containing e-cigarettes are not first-line treatment for smoking cessation and there are no products that have been evaluated and approved for therapeutic use,’ Professor Zwar said.
The guidelines state the use of e-cigarettes is controversial and the long-term safety profile is still emerging, with a lack of current evidence and the potential to promote and normalise nicotine use.
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