Health professionals, and particularly general practitioners (GPs), are in a unique position to provide quit advice to their patients. In 1988-1989 there were 79.2 million attendances for GPs and another 12.8 million for medical specialists. Further, a higher proportion of these attendances would have been by smokers than non-smokers.(29)
The influence of GPs, in the traditional one-to-one relationship with the patient, is very powerful. Particularly in the case of older people, orthodox health professionals are the single most important source of information about health and lifestyle,(30) although there is also evidence that adolescents are responsive to healthy lifestyle information delivered in a general practice setting.(31,32)
American research has shown that smokers who had received non-smoking advice from their doctor were nearly twice as likely to try quitting.(33) Australian research has shown a preference among potential quitters for advice and programs conducted through their doctor or another health professional.(34) A number of studies have shown a small but significant increase in cessation where doctors have, in the course of a consultation, given smokers brief quit advice and simple resource material.(35,36,37) Overall, the most reliably effective intervention programs in the physician/health professional setting are those providing firm, consistent and repeated help and advice to stop smoking.(38)
The 'Sick of Smoking' program, devised in South Australia,(37) is a minimal intervention program which has been evaluated. The 'Sick of Smoking' kit included explanations of risks involved in smoking and benefits of cessation, visual display materials to help GPs explain relevant disease processes to their patient, a pad of tear-off information sheets to give to patients, a booklet on quitting, and referral information for those seeking further support. The GP advised patients to stop smoking, and that their smoking status would be recorded in their case notes and followed up in future consultations. The program was designed to be conducted as part of a normal length consultation, and was intended to be implemented on an opportunistic basis by the GP.
The study found that the intervention produced a quit rate of 7.5%, compared to 3.2% in the control group -- an excess of 4.3% quitting. If patients who had 'dropped out' were excluded, the quit rate for the intervention group was 11.3% compared to 4.8% in the control group -- an excess of 6.5%.
The authors comment that although these figures may seem small, in public health terms they are very large. They observe that:
A quit rate between 7.5% and 11.3% means that a minimum of 220,000 smokers would quit each year in Australia, given the proportion of people who attend their general practitioner in a one year period and a smoking prevalence of 30%. Æ Even if only half of all general practitioners in Australia tried the program and half of those continued to use it, then over a one year period the smoking prevalence would be reduced by 55,000 smokers or 1.5%.(37)
An alternative to minimal intervention is a more highly structured program also designed for doctors' use. An Australian study documenting the use of a more extended program by GPs (involving six patient visits over six months, plus the provision of prescribed literature) showed a 33% abstention rate among the intervention group after six months, compared to a 3% abstention rate among a control group.(39) The authors concluded that the total additional costs of the patients' visits was a fraction of the cost of medical treatment for a cigarette related disease. However programs of this dimension require a high degree of commitment by the doctor and their success may be compromised in an uncontrolled environment.(29,40,41) There is also some debate about whether structured programs requiring a number of visits are currently rebatable under Medicare.(29,42)
It may be that there is a role for a variety of GP programs of varying style and intensity, to suit individual GP style and patient need.(43) At any rate, the question of 'what type of intervention' is secondary to the question of 'how do you get doctors to get involved in the first place'.(44) A Victorian study from 1990 showed that one in five smokers did not recall having been asked by their GP if they smoked, nor having received any advice on smoking, and that only 55% of smokers perceived their own doctor as being against smoking.(9) Other Australian surveys have reported disappointingly low levels of advice on smoking being routinely given by GPs to their smoking patients.(45,46)
There is a clear advantage in encouraging medical professionals to provide their smoking patients with advice to quit, and in ensuring that medical practitioners have access to suitable materials to assist in this. Doctors are more likely to use an intervention program if it is brief, can be used as part of a normal consultation, is well resourced, and is 'user friendly'.(37,47) They also need to be introduced to the materials in a way which is cost effective, yet likely to encourage their use.(48) Although the success rate may seem discouragingly low to the individual GP, overall they would be contributing to a major impact on public health.(49) This impact could be broadened considerably if medical specialists, dentists, community and hospital nurses, physiotherapists, pharmacists and other health professionals were involved in motivating cessation.
There is evidence that doctors have difficulty detecting whom among their patients are smokers. An Australian study found that GPs detected just over half of their smokers.(50) The reasons for this are not clear: it may be that younger smokers were overlooked because they were less likely to present with a smoking related problem, or that smokers go to lengths to conceal their smoking from their doctor, or that doctors rely on their intuition about smoking status rather than asking directly.(49) This has implications for the success of GPs' practice-based intervention programs.