Results

No significant differences were found between responses from the first and second wave of respondents, suggesting that bias as a result of non-response was minimal.17

Almost all GPs (96%) and practice nurses (99%) believed that it was part of their job to advise and assist smokers to stop. Table 1 shows that while recording smoking status at registration was almost universal, and recording advice given was also common, routine monitoring of smoking status was less so.

Table 2 shows that most practice nurses and half of GPs reported that they advised smokers to stop at most or all consultations, although 98% of GPs did report advising smokers to stop at least every now and then. Advising smokers to cut down was commonplace.

Table 2 also shows that providing assistance of various kinds was quite common among GPs; 41% said they provided counselling and 57% gave out leaflets. Referral to the practice nurse was the most frequent kind of referral and that was undertaken by 41% of GPs. Forty three per cent of nurses said they received referrals of smokers from their GPs. Nurses reported that assistance for smokers primarily involved handing out leaflets and individual counselling. Very few GPs or practice nurses ran stop smoking groups. The Quitline (the national telephone helpline run by the national charity, Quit) was recommended by a majority of nurses.

Table 2 shows that recommending patients to use NRT was common, with the patch being the most popular form. Prescribing was far less common. (In general this would have to be via private prescription.) On the other hand, 26% of practice nurses reported not recommending any form of NRT, and a significant minority of GPs (17%) reported that they neither recommended nor prescribed any form of NRT.

When asked about the sources of their smoking cessation materials (leaflets, videos and audio-cassettes): 44% of GPs said they obtained them from the Health Education Authority, 36% said from their local health promotion department, 14% said from commercial companies, and 9% said from Quit. Eight per cent of GPs and 15% of practice nurses said their practice owned a carbon monoxide monitor. Among nurses who used leaflets, 81% said they obtained them from their local health promotion department, 63% obtained them from the Health Education Authority, 30% from commercial companies, and 30% from Quit.

Table 3 shows that most GPs believed that NRT was effective but only a minority thought it was sufficiently effective to justify its cost and even fewer thought it should be made available on NHS prescription. A minority similarly thought it should be made available on general sale. Table 3 also shows that while a large majority of nurses thought NRT was effective, fewer thought it justified the cost or should be made more available.

When asked what proportion of smokers typically stop smoking for good as a result of GP advice the average was 10.4% (SD 10.3) among the 253 GPs who offered an opinion. The modal value was 5% and the median was 8%. When asked a similar question about what proportion of smokers typically stop smoking for good as a result of advice from a practice nurse the average was 10.9% (SD 13.2) among the 294 nurses who responded. The modal and median values were both 5%.

Most GPs (70%) and practice nurses (74%) recognised that switching to a low nicotine cigarette would not significantly reduce smokers' risks of lung cancer; only 7% of GPs and 6% of nurses thought it would halve the risk but 23% and 19%, respectively, said they did not know.

A total of 28% of GPs said they had received training on the delivery of smoking cessation advice. There was no evidence of differences between trained and untrained GPs in terms of monitoring smoking, giving brief advice, giving assistance, recommending NRT or referring to other sources. Only 4% of GPs reported that they smoked and the numbers were too small to be able to make comparisons between the responses of the smokers and the non-smokers.

There was no evidence of associations between the age or sex of GP and practice nurse and monitoring smoking, giving advice, recommending NRT, and providing assistance or referring.

Sixty six per cent of practice nurses said they had received training on the delivery of smoking cessation advice. Practice nurses in group practices were more likely than those in single GP practices to report having received training in the giving of smoking cessation advice (χ² = 15.1, p < 0.001).

Practice nurses who reported having received training in the giving of smoking cessation advice were more likely than those who had not to say that they provided assistance for smokers wanting to stop (counselling, leaflets, etc, χ² = 51.5, p < 0.001). In particular they were more likely to say that they provided counselling for smokers wanting to stop (χ² = 73.7, p < 0.001), handed out leaflets (χ² = 5.9, p < 0.05), ran a stop smoking group (χ² = 9.9, p < 0.01), and received referrals from GPs in the practice (χ² = 49.2, p < 0.001). The practice nurses with training were also more likely to report that their practice owned a carbon monoxide monitor (χ² = 4.4, p < 0.05). Practice nurses who had been trained in smoking cessation were more likely to advise patients to telephone the Quitline (χ² = 4.6, p < 0.04), and less likely to refer smokers to an alternative therapist (χ² = 4.9, p < 0.05). They were also more likely to believe that if a smoker changes from high to low nicotine cigarettes the risk of lung cancer stays the same (χ² = 8.5, p < 0.05).

Practice nurses with training were more likely to report recommending NRT (χ² = 3.9, p < 0.05), to believe that NRT is effective enough to justify its cost (χ² = 15.1, p < 0.001), and to believe that NRT should be on general sale (χ² = 11.1, p < 0.01).

Discussion

Study 1 found almost universal acceptance that smoking cessation interventions are part of the GP's role. In line with this almost all GPs recorded smoking status when patients joined the register and reported that they advised patients to stop at least every now and then. However, providing routine advice to stop was not so common and neither was recording whether advice had been given nor regular updating of records on smoking status of patients. The regular updating of records as to patients' smoking status and advice given are considered to be important as a precursor of future interventions and as a prompt for GPs.4 Interestingly, a majority of GPs said that they advised cutting down as an alternative to stopping. GPs were quite likely to provide some form of assistance to smokers wanting to stop. There was general acceptance of the effectiveness of NRT and most GPs said they recommended patients to use it. However, a significant minority did not recommend or prescribe NRT and only a minority believed its cost could be justified. There was no evidence that training had any major impact on GPs' behaviour, attitudes or knowledge.

Study 2 found that almost all nurses accepted that intervening against smoking was part of their role and a majority said that they advised smokers to stop at most consultations. As with the GPs, advice to cut down was commonplace. There appeared to be quite a high rate of smoking cessation activity among practice nurses and most said that they recommended NRT. As with the GPs there was widespread acceptance of the effectiveness of NRT but less acceptance of the cost-effectiveness. There was a clear positive association between training and activity, attitudes, and knowledge.

The findings are promising in terms of establishing that GPs and practice nurses are undertaking smoking cessation activities to some degree, but bearing in mind that respondents may have felt pressure to report a high level of activity, there is some way to go before the new guidelines on smoking cessation in general practice are implemented in full. There are many barriers to routinely advising smokers to stop, which requires up-to-date records of smoking status and past advice.18 GPs may feel more comfortable with providing assistance when smokers want it (for example, when patients are suffering from smoking related conditions18) because this fits rather better with expectations of the consultation. In this regard, recommendations about NRT seem to play a central role for most GPs. Practice nurses appear receptive to the role of smoking cessation facilitator and they are also generally aware of the possible benefits of NRT.

It has been previously thought that lack of time was a key factor in preventing GPs from routinely advising smokers to stop but there may be other factors. The treatment of disease is very much the dominant theme of undergraduate and postgraduate training and the NHS still operates very much in “response mode” with patients presenting with a complaint and the health service attempting to solve the patient's problem. This is a matter of ethos and the context within which GP consultations occur. Finding time to raise a topic that was not the reason for a consultation and developing the skills to do so in a way that does not interfere with the doctor-patient relationship is still a major challenge.

Anecdotal reports have suggested that GPs and nurses often advise smokers to cut down if they cannot stop but to our knowledge this is the first systematic survey addressing the issue. It is generally thought in the research community that cutting down is unlikely to be a useful option because smokers compensate for the reduced number of cigarettes by smoking each one more intensively and almost invariably resume their previous level of consumption quickly.19There is also a danger that this advice is counterproductive by alleviating the pressure to stop. For this reason the smoking cessation guidelines focus exclusively on stopping rather than cutting down, and the US equivalent specifically recommends against advising to cut down.20

It was interesting that a significant minority of GPs and practice nurses did not accept NRT as a suitable form of treatment. Further work is needed to explore why this might be. Also of interest is the fact that GPs and practice nurses had in many cases not accepted that NRT was cost-effective, nor that it should be provided as part of NHS treatment. This may be because of a perception that it is expensive considering what they believe it costs to produce or because of a perception that smokers have brought their problem on themselves. It would be interesting to examine this further by assessing their factual knowledge of the cost per life year gained from use of NRT and their beliefs about smokers' own responsibilities in causing their problems.

The lack of association of training and behaviour, attitudes and beliefs among GPs is noteworthy. It is not clear what undergraduate training GPs receive, if any, or what is currently being undertaken, although it is most likely to be short sessions such as study days. On the other hand, the association between behaviour, attitudes and knowledge and training in practice nurses suggests that training can have some effect. There are several training programmes in operation for this group apart from study days (for example, the Health Education Authority's Helping People Change programme). More evidence is needed on what kinds of training nurses and GPs receive and which forms are more effective than others. Of course, it is also possible that nurses who go on such courses are already more interested in smoking.

These studies are limited by the fact that they rely on self report and so self presentation bias cannot be ruled out. Another factor may be the fact that the database used included a number of GPs who had moved or were no longer practising. There was an under representation of single handed practices in the GP survey, but since we found no difference between single handed and group practices we believe this is unlikely to have affected the results.

CONCLUSION

Many GPs are routinely advising smokers to stop and monitoring smoking status, but the level of activity is somewhat below what is recommended in the new national guidelines. On the other hand many GPs appear to be providing some assistance to smokers wanting to stop, and most are recommending NRT. Practice nurses are generally active in trying to help smokers wanting to stop and they too believe it appropriate to recommend NRT. This survey indicates that there is a considerable amount of activity already taking place in primary care and ways need to be found to increase it, bearing in mind the barriers that exist. The authors of the guidelines recognised that their publication represented the start of the process, and this survey has provided some information on the baseline from which one is operating.