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As we reported, this trial took place in the UK National Health Service (NHS) Stop Smoking Service. The NHS has developed standards for training in behavioural support.1 Stop Smoking Service coordinators oversee this training and the quality of services provided in the NHS, which may involve fidelity checks and, in the region we studied, mandatory annual update training.
Greaves emphasises psychological techniques that he states are necessary for the efficacy of behavioural support. Trials in smoking cessation do not show whether or not particular forms of behavioural intervention—such as cognitive behavioural interventions—are necessary for effect or whether one form is more effective than others.2 3 Some components that Greaves suggests are essential—such as relapse prevention—have been shown to be ineffective.4
Behavioural support for smoking cessation in the UK is based on withdrawal orientated therapy.5 This recognises that individuals come to clinical treatment services when they are highly motivated to stop but cannot do so because of nicotine dependence. The goal of therapy is to help reduce withdrawal discomfort during the first few weeks. Motivational enhancement is not usually part of treatment.6
Greaves assumes that by “specialists” we mean an army of health psychologists. We do not. The NHS provides two types of face-to-face NHS stop smoking support. One is by primary care nurses trained and monitored as we described. The other is by people who have undergone the same training but provide smoking cessation support as their main role. Frequently such specialists are nurses, but other professions are represented, although few psychologists do this work for the wage offered. The evidence from prospective evaluations is that the same kind of care provided by such specialists produces double the quit rate we saw in our study.7 The difference in efficacy is not because of different training.
Evidence from other studies showing that behavioural support is ineffective even where high quality training was given to primary care professionals8 9 reinforces our belief in the superiority of effectiveness of specialist over generalist support. Perhaps the other demands of the role of providing general care, or the appointment system that militates against regular support, lead to failure of trained generalists to equal the success of similarly trained specialists in smoking cessation. Until the NHS shows in independent evaluations that higher quit rates can be obtained in primary care, our advice would be for primary care professionals to refer smokers to specialist support or provide brief advice, using pharmacotherapy in both cases.