Improving the effectiveness of smoking cessation in primary care: lessons learned

The 'Smokescreen' smoking cessation programme was introduced in Christchurch in 1995, with an initial study showing six-month, self-reported quit rates of 10% and 17% (with a validated deception rate) in primary and secondary care settings. Substantial modifications were made to try to improve this rate in the primary care setting and the programme has been implemented widely. Our primary aim was to estimate programme utilisation and six-month quit rates for enrolled patients in this general primary care setting. We also aimed to use a wide range of patient, practice and environmental variables to estimate any predictive effect on outcome.

Prospective longitudinal cohort study. The nicotine replacement therapy (NRT) -based programme was implemented by Pegasus Health, an independent practitioner association (IPA) situated in the Christchurch urban area, to which the majority of Christchurch-based GPs belong. A cohort of 516 patients enrolling in the programme over a two-month period were contacted six months after their nominated quit date. The main outcome measure was the six-month, self-reported quit rate.

Of the 516 participants, 334 (65%) were contacted by mail or telephone. The overall six-month quit rate was 36% (95% Confidence Interval (CI) 31-41). Univariate analysis initially showed duration of NRT (p = 0.03) and age band (p = 0.004) were significant predictors of quitting, while living with a smoker (p = 0.02), having made no previous quit attempts (p = 0.02) and having heart disease (p = 0.01) were all significant predictors of continued smoking at six months. Factors that did not predict whether respondents were smoking at six months included previous use of NRT, sex, ethnicity, who delivered the intervention, years of smoking, cigarette dose, and NZDep96 score. However, there was interaction between these factors as after multivariate analysis the only significant predictors of outcome were having others living in the house who smoked (odds ratio (OR) 0.55, 95% CI 0.33--0.93, p = 0.03) and having made no previous quit attempts (OR 0.29, 95% CI 0.12-0.71, p = 0.02). Both these factors were significantly associated with continuing to smoke.

This programme compares favourably with six-month quit rates for NRT-based programmes reported in the international literature of 14-22%. The effectiveness of an NRT-based smoking cessation programme in a general primary care setting appears to have been significantly enhanced by local adaptation, the flexibility of a primary-care-team approach and subsidisation of NRT, together with facilitation responsive to individual practice needs. The success of this programme in helping individual patients quit, as well as its successful implementation in a wide primary care setting, suggests General Practice can play an important role in smoking cessation in a country with a high burden of disease from smoking-related illnesses. The programme is congruent with the current, national, smoking cessation guidelines endorsed by the RNZCGP. Widespread adoption of this kind of model in IPA/primary health organisation (PHO) settings throughout New Zealand should be encouraged and supported.