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The trial reported by Aveyard et al1 in a recent issue of Thorax is a welcome illustration that primary care nurses are not being trained properly to deliver the behavioural support aspects of smoking cessation. However, the paper seems to miss this point and instead concludes that “Primary care smoking cessation treatment should provide pharmacotherapy with sufficient support only to ensure it is used appropriately, and those in need of support should be referred to specialists”.
We know from a large body of previous work and systematic reviews (as referenced in the article) that well considered and planned behavioural support doubles the increase in quit rate for smoking cessation services. In this trial, however, there was no effect. The results therefore clearly show that the current form of nurse-delivered “behavioural support” is ineffective. Indeed, I am concerned that the authors even refer to what was delivered as behavioural support. There is no evidence that any established behaviour support techniques were delivered (eg, motivational assessment, elicitation and examination of barriers, use of action and coping plans, establishing self-monitoring regimes, use of established relapse prevention techniques). Simply asking nurses to conduct some extra telephone calls and visits without any specification of the content is pointless in terms of applying behavioural science. There is therefore a grave danger that trials such as this will be included in future systematic reviews as trials of behavioural support, even though the quality of the support offered was non-existent (or at least not established in any way). This kind of data may bias future reviews.
Furthermore, the lack of effectiveness of the nurses in this study does not mean that nurses cannot be trained to deliver this support (as the authors seem to suggest). It is my experience—and that of many other behavioural researchers2 3—that almost anyone can be trained to effectively deliver simple behavioural support techniques such as motivational interviewing, which are the same techniques commonly used in smoking cessation and have proved to be effective in the NICE and Cochrane reviews.
Yes, passing patients on to specialists would produce a much needed workstream for the hundreds of graduate health psychologists qualifying each year, but another alternative would be to train the nurses properly to do the job. This trial tells us nothing about the pragmatic effectiveness of behavioural support, as no behavioural support was apparently delivered.
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