GPs and nurses who treat smoking as a clinical dependence and not just a lifestyle choice are more effective in referring people to cessation services.

When doctors and nurses start dealing with smoking as a clinical issue rather than a lifestyle choice, the Department of Health’s new smoking cessation service will be more than halfway there. The shift in attitude heralds a new approach to how the problem should be dealt with.

“What we’re trying to get clinicians to do is to recognise that smoking is often not a matter of choice - that it’s maintained by tobacco dependence,” says Paul Aveyard, a GP in Solihull and senior lecturer at Birmingham University’s department of primary care clinical sciences.

That includes seeing tobacco dependence as a condition that is worthy of and is amenable to treatment, just like high blood pressure, for example.

At the moment, even among smokers who are motivated to quit, when they discuss smoking with their GP, treatment is offered in a minority of cases.

The DH recommends that clinicians use the 30-second “ask, advise, act approach” to helping smokers quit. It involves asking patients whether they smoke and, if they do, advising them to quit by using the NHS stop smoking service, and then referring them to the service. Clinicians will be more likely to refer to the service if they know what it does, that it works, and how to refer.

“The stop smoking service has a pivotal job in making sure primary care practitioners understand the principles and the evidence base, the fact that these services aren’t fluffy lifestyle services, they’re clinical intervention services,” says DH smoking cessation service delivery manager Emma Croghan.

Proper referrals

That is why stop smoking services are changing their behaviour too, so they act like a proper clinical service that receives proper referrals from clinicians and communicates on the outcome and any necessary further treatment.

In the same way that pharmaceutical representatives visit practices and talk to GPs to motivate them to prescribe the drugs they sell, stop smoking service advisers are visiting GPs and practice nurses to tell them why the service is needed, the benefits for patients, and how to refer.

With so many practices in each patch, advisers will prioritise which to visit so they get the most bang for their buck, says Ms Croghan.

Stop smoking services will use national, regional and local data sources to help them identify practices where they can get the biggest wins so that they can visit them first.

Case study: improvement in Rotherham

The Dinnington Group Practice in Rotherham has worked closely with NHS Rotherham to develop a protocol for assessing and recording smoking status, identify what training was needed, how it would do the referrals, and get promotional materials ready.

There are three stop smoking clinics, which are run by a stop smoking service adviser from the primary care trust and two healthcare assistants from the practice, who received training from the PCT.

With more than 20,000 patients, in 2008 the practice made 122 referrals to the service, of which 116 were set to quit. In the previous year there were just 20 referrals.

“We have a waiting list of people that are wanting to stop smoking,” says deputy practice manager Janet Mousney.

She puts the increase in referrals to the service down to a number of factors, including the fact that it is now done in Dinnington, whereas before patients had to travel elsewhere.

“We’ve got a good link with the PCT and I think that always helps,” she adds. “And it’s having people who are enthusiastic, like the two healthcare assistants, who were really interested in doing the training. The doctors, nurses and staff are on board with it, which makes a big difference.”

Reception staff have also had training so they can encourage patients who mention they smoke to use the service.

Posters are displayed in the practice and staff use every opportunity to promote the service. For example, as they give flu vaccines on three Saturdays they also asked people at those clinics whether they smoked and if they wanted to stop.

The practice’s scores in the quality and outcomes framework have more than doubled and currently stand at 92 per cent for smoking status recorded and 87 per cent for smoking advice and referral to specialist.

Quarterly audits are used to feed back results to the PCT and to practice staff. As Ms Mousney says: “It’s nice to know that we’re improving something.”

Irene Botham, clinical nurse manager at the practice, says the service has a dramatic impact on long term conditions such as chronic obstructive pulmonary disease, coronary heart disease and asthma. “The more people we can get to stop smoking, the lower our rates of chronic disease should be in practice.

“The patients certainly praise the nurses who are doing it. Most of them will say ‘we couldn’t have done it without their help’.”


Every PCT has a stop smoking service. Clinicians can visit the DH’s smokefree website and enter their postcode to obtain contact details.