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Helping people to stop smoking: the new smoking cessation guidelines
  2. A J KNOX
  1. Division of Respiratory Medicine
  2. City Hospital
  3. Nottingham NG5 1PB
  4. UK

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Cigarette smoking is probably the most damaging of all voluntary human behaviour. Half of all smokers die prematurely as a consequence of their own smoking,1 and in 1995 in the UK alone smoking accounted for over 120 000 deaths, of which about 65 000 were due to respiratory disease.2 In addition to the harm caused to smokers themselves, passive exposure of other adults to cigarette smoke is associated with increased respiratory morbidity3 and an increased risk of lung cancer and heart disease,4 ,5 whilst children brought up by parents who smoke are more likely to experience lower respiratory illness in infancy,6 sudden infant death,7and middle ear disease, wheezy bronchitis and exacerbation of asthma in childhood.8-10 In addition to these direct effects of tobacco smoke, cigarette smoking affects health indirectly through the cost to the individual of sustaining their smoking habit, which contributes to financial hardship and consequent deprivation of smokers and their dependents. The total social, economic, and health related cost to society of smoking is enormous, and prevention of smoking therefore deserves to be a major priority for all health professionals. Respiratory physicians should have a particular interest in smoking prevention because so much of the morbidity and mortality caused by smoking manifests as respiratory disease.

Preventing smoking, particularly at the primary level, is a major task and, as is often the case, the power to enact radical preventive public health measures lies with politicians more than doctors, though the medical profession certainly has its role to play in driving that political debate. At the level of secondary prevention, however, effective means of helping people to stop smoking have been available to the profession for many years, yet for various reasons it has failed to apply them. Part of the reason for this is perhaps that smoking has tended to be, and is still widely perceived to be, a matter of personal choice rather than an addictive behaviour. Today’s doctors were not taught about the addictive nature of smoking or its treatment and, as other articles in this issue of Thorax point out,11 ,12 nor is the current generation of medical students. Hence, despite the fact that it is now nearly 20 years since Russell and colleagues documented the effectiveness of simple advice from the primary physician to give up smoking,13relatively few doctors routinely apply even this simple intervention, let alone more intensive cessation support. Smoking cessation services have never been a high priority for National Health Service planners and managers and, despite established clinical evidence of efficacy,14-16 nicotine replacement therapy (NRT) has not generally been available on the NHS. In fact, NRT approximately doubles the cessation rate achieved by non-pharmacological smoking cessation interventions,15 ,16 a level of efficacy which for most interventions in medicine would be more than sufficient to justify widespread use. Even if at an individual level the chance of successful smoking cessation after these or related interventions is modest, the effect across the population in terms of numbers of ex-smokers generated and morbidity and mortality avoided should be substantial. That, surely, is the justification for many other modestly effective and routinely used therapeutic interventions in medicine. Smoking cessation should be no exception.

As a supplement to the December issue ofThorax we published two documents that we hope will provide a major impetus to the development of smoking cessation services. The first, Smoking Cessation Guidelines for Health Professionals 17 summarises the background evidence for smoking cessation interventions and provides clear guidelines to various groups of health care professionals as to how they can influence smoking behaviour, and what they should be doing to achieve this. The fundamental themes are the systematic ascertainment of smoking status in all patients, the provision of advice and assistance to those who want to try to give up smoking, and recommendation of nicotine replacement therapy where appropriate. The basic structure of these interventions and references to further sources of practical information on service design and provision are provided within the document. Recognising that these are initiatives that cannot occur without the will and support of health authorities and primary care groups, the guideline also makes the appropriate recommendations for health commissioners as well as for health care professionals.

For those who wish to see the numerical evidence on the size of the health gain likely to be achieved by smoking cessation intervention and the cost implications of providing these services, we have also published Guidance for Commissioners on the Cost Effectiveness of Smoking Cessation Interventions.18This document spells out the financial cost of smoking to our society, the expected cessation rate for different levels of intervention, the cost to commissioners of providing these interventions, and the estimated cost per life year saved. The basic messages are that the total cost to society of brief advice from a doctor with the provision of self help materials is approximately £260 per life year saved and, with the full costs of nicotine replacement therapy included, it is less than £700. Compared with the total societal costs of most other medical interventions19 this represents extremely good value for money. It is time for the medical profession to start to take smoking cessation seriously and, as specialists in respiratory disease, we should be particularly proactive in ensuring that smoking cessation support becomes a systematic and routine component of health care delivery.