What Happens When GPs Proactively Prescribe NRT Patches In A Disadvantaged Community

L Copeland*, R Robertson*#, R Elton+ *Muirhouse Medical Group, 1 Muirhouse Avenue, Edinburgh (# also Department of Community Health Sciences-General Practice, University of Edinburgh) +Statistical Services, 5 Wilton Road, Edinburgh

Correspondence to: Lorraine Copeland, Research Associate, Muirhouse Medical Group, 1 Muirhouse Avenue, Edinburgh EH4 4PL Tel/fax: 0131 332 2984 

e-mail: lorrainecopeland@aol.com

SMJ 2005 50(2): 64-68

 

Abstract

Background and Aims: The high prevalence of smoking in disadvantaged communities gives serious cause for concern in terms of adverse effects on health and social outcomes. In Scotland, smoking –related lung cancer rates are particularly high and compare less favourably with the rest of the UK and Europe. GPs are increasingly being recognised as having an important role in smoking cessation and are allowed to prescribe NRT to those on a low income. This study aimed to follow up a group patients from a disadvantaged area who had been prescribed nicotine patches by their GP. Methods: An initial self-complete questionnaire gathered details on age, sex, motivation, marital status, employment history, contact with other smokers, concern about weight gain, and nicotine dependence. (Nicotine dependence was assessed by using the Fagerstrom Test). Follow up was carried out at three months after commencing NRT prescription. Data was also gathered from patient case notes as to whether the participant had a smoking-related diagnosis, periods of depression, drug and/or alcohol problems. Outcome was measured in terms of “smoke the same”, “smoke less” and “stopped”. The statistical methods used for testing each factor against smoking were Spearman rank correlation, chi-squared test for trend and Kruskal- Wallis test. Basic descriptive statistics were used to report general outcomes of the study. Results: The study enrolled 120 patients but 19 were lost to follow up. Out of 101 who used their prescription, 35 were smoking the same, 46 were smoking less and 20 had stopped. The variables most strongly affecting outcome were age, with older smokers having more success (p<0.001), and those who had a diagnosis of depression having a worse outcome in terms of smoking cessation (p<0.05). Conclusion: This study’s findings indicate that encouraging GPs to take a proactive approach in prescribing NRT is effective, even in an area of socio-economic deprivation, and particularly with older smokers. 

 

Introduction 

In the UK the most recent estimates show that around 106,000 people are killed by smoking every year.1 Smoking causes at least 80% of all deaths from lung cancer, around 80% of all deaths from bronchitis and emphysema and around 17% of all deaths from heart disease.1 It is also a habit that tends to prevail in more disadvantaged communities and it is generally recognised that any marker of disadvantage that can be envisaged and measured, whether personal, material or cultural, is likely to have an independent association with cigarette smoking.2 Those living in disadvantaged communities are recognised as being more likely to start, and sustain, a smoking habit.3 Smoking also accounts for two thirds of the difference in life expectancy between the rich and the poor.4 

 

In Scotland, smoking rates are higher than in England and Wales, with about 1.2 million (30%) of adults who currently smoke.5 In disadvantaged groups, rates are five times higher among women and three times higher among men than in the most affluent. Scotland is also noted as having the highest lung cancer rates in Europe for both men and women, with most cases caused by smoking and 20-25% of the population die from smoking-related causes. Again, it is one of the main reasons why those who are disadvantaged are more likely to have poor health and die younger.5 

 

With such a dramatically negative effect on the population’s health, particularly in disadvantaged communities, it is not surprising that there have been many proactive attempts to influence smoking cessation from anti-smoking organisations and more recently the current government. Arguably any sustained changes in the UK’s smoking patterns are likely to emanate from government led directives and interventions. The current government’s White Paper “Smoking Kills” announced there would be legislation to end tobacco advertising and sponsorship, a media campaign to change behaviour, tough enforcement of underage tobacco sales and new NHS services to help people who want to stop smoking.4 

 

In 1999, the Scottish Executive further emphasised its own commitment to reducing smoking in targets laid out in its White Paper on Health. Targets were set for reducing adult smoking (from 35% in 1995‚ to 33% in 2005 and 31% in 2010)‚ smoking prevalence among 12-15 year olds (from 14% in 1995‚ to 12% in 2005 and 11% in 2010)‚ and smoking in pregnancy (from 29% in 1995‚ to 23% in 2005 and 20% in 2010).6 In 2003, the determination of NHS Health Scotland to continue to advocate smoking cessation was further emphasised with the publication of a combined report with ASH Scotland.5 One of the key recommendations of this report was that a huge expansion in smoking cessation services was needed to help many more people to stop smoking. 

 

As an instrument of health directives from government bodies, healthcare workers have a vital role in the success of smoking cessation interventions in all groups of society, perhaps even more so in disadvantaged communities. Demographic characteristics of these communities such as low income or unemployment can result in more frequent consultations with GPs than occur in more affluent communities.7 Involving GP surgeries in increased provision of smoking cessation services has the obvious benefit of using an infrastructure that is already in place and is accessed regularly by those living in disadvantaged communities and is in keeping with the recommendation to expand smoking cessation services.5 

 

In particular, it has been recognised that GPs are usually the first point of contact for smokers with health problems and as such GPs have recently been encouraged to give smoking cessation support for patients. Recommendations urge GPs to discuss smoking repeatedly and as frequently as possible.8 What practical help can GPs offer to smokers who want to quit? It has been shown that brief GP advice during a consultation can aid smoking cessation and is very cost-effective.9 As well as the advice-only approach there are effective approaches to smoking cessation which include behavioural intervention and pharmacotherapy and can involve the GP. 

 

Evidence for success of  NRT 

Nicotine replacement therapy (NRT), remains a popular choice of smoking cessation intervention for many smokers. A Cochrane Review based on 123 trials, 103 contributing to the primary comparison between NRT and a placebo or non-NRT control group found that it achieved 1.5- to >2- fold increases in smoking cessation rates regardless of the setting in which it is administered. The main outcome measure used was abstinence from smoking after at least six months of follow up.10 Although NRT is widely recognised as having success in helping smokers to quit, there are indications that this success is not uniform throughout society. Some studies have shown that age, sex, socio-economic status, marital status and nicotine dependence are determinants of success and that there is higher success in males, older subjects, those living with a non-smoking co-habitant and those with higher socioeconomic status.11 , 12 , 13 

 

It has been shown that smoking cessation rates achieved with NRT were as good with over-the-counter sales as they were with issued prescriptions.14 The cost of over-the counter NRT was bound to have been a deterrent to people on a low income should they want to try it. Stapleton, Lowin & Russell15 ,(1999) estimated that if GPs were allowed to prescribe transdermal nicotine patches on the NHS, for up to 12 weeks, the incremental cost per life year saved would be: £398 per person younger than 35 years; £345 for those aged 35–44 years; £432 for those aged 45–54 years; and £785 for those aged 55–65 years. The low cost per life year saved would make GP intervention against smoking a cost-effective life-saving treatment. Concurrent with this line of thought, NRT has been available free of charge to people on low income since May 2001. However, to date there has been no research undertaken to monitor whether this effective antismoking therapy is being prescribed appropriately.16 

 

Motivation and obstacles to cessation 

For an attempt to stop smoking to be successful, the smoker must want to stop. Over 70% of smokers say they would like to quit and this is similar across different income groups and whether or not children live in the household.17 Why do most attempts fail? Many smokers appear to use the most ineffective method - cold turkey - and few smokers report receiving help. Motivation is obviously strong but is being harnessed ineffectively. In addition, smoking is now commonly recognised as nicotine addiction and, as an addiction, produces symptoms of dependence and withdrawal germane to addictive behaviour and obstructive to cessation attempts. Like other addictions, trying to give up smoking has a remitting and relapsing element.18 In disadvantaged communities, the problems of overcoming this addiction are also compounded by the strong cultural hold smoking exercises over this population, primarily as a coping mechanism.19 , 20 , 21 

 

The advantages in drastically reducing smoking rates would obviously be found in the arena of the population’s health but the wider implications for society can be seen if we look at breaking the pattern of the social norms surrounding smoking in certain groups of the population, particularly those living in deprived circumstances. 

 

Methods 

The aim of this study was to follow up a group of patients from an area of socio-economic deprivation who had been prescribed nicotine patches by their GP, following a GPinitiated smoking cessation discussion, to discover what the outcome of this intervention was in terms of smoking cessation in a group with acknowledged difficulties in achieving this.3 The study took place in a general practice in North West Edinburgh with over 10,000 patients managed by 7 GPs in 2003. The practice is situated in an area which is recognised as having markers of socio–economic deprivation such as high unemployment, heavy use of primary care services and a high prevalence of smoking.2, 3, 7 

 

One hundred and twenty patients were opportunistically recruited into the study and there was no indication that participants were not representative of the practice area’s population in their general characteristics. The majority of patients recruited into the study came to consult their GP on another matter and their GP then initiated the smoking cessation aspect of the consultation and subsequent prescription. 

 

Inclusion criteria were that the patient was a current smoker and was willing to participate in the research study. Recruitment took place over a period of three months, when GPs were about to prescribe NRT, the patient was informed about the project and given a detailed introductory letter. All of the seven GP partners participated in the recruitment of patients. If the patient agreed to participate, signed consent was obtained and they then completed the study enrolment form at the end of the consultation. This form gathered data on age, sex, motivation, marital status, employment history, contact with other smokers, concern about weight gain, nicotine dependence. Nicotine dependence was assessed by using the Fagerstrom Test, a validated measure which is copyright but which GPs are allowed to use for clinical purposes.1 This test allows GPs to quickly assess nicotine dependency in a general practice setting. In this test a score of 0–2 indicates very low dependence, 3-4 indicates low dependence, 5 indicates medium dependence, 6-7 indicates high dependence while 8 or more indicates very high dependence. 

 

These questions were incorporated verbatim into the study enrolment form. A copy of this form was held by the researcher and also placed in the patient’s case notes. Data was also gathered from patient case notes as to whether the patient had a smoking-related diagnosis, periods of depression, drug and/or alcohol problems. Diagnostic categories were decided on by the GP who supervised the researcher’s fieldwork. The statistical methods used for testing each factor against smoking cessation were Spearman rank correlation, chi-squared test for trend and Kruskal-Wallis test. Basic descriptive statistics were used to report general outcomes of the study. 

 

Patients were contacted at three months from commencement of using NRT. Follow up was carried out firstly by post. After three postal contacts, the follow up form was placed in the patient’s case notes for completion the next time the patient consulted with his/her GP. Sixty (59.4%) returned their forms by post and 41 (40.6%) completed them after a surgery consultation. The follow up form gathered data on whether or not the prescription was actually used, what the outcome was in terms of smoking the same, smoking less or stopping, and why the patient felt they succeeded or did not succeed using nicotine patches. (An outline of the proposed study was sent to The Chairman of the Primary Care/Public and Mental Health Research Ethics Committee (Lothian) who decided that the study did not require formal ethical approval as the proposed intervention was already acknowledged as beneficial to patients and informed consent was to be obtained if participants agreed to take part). 

 

Results 

The original sample size was 120. It was interesting to note that all of the original sample group initially agreed to participate when approached, perhaps indicating the strength of desire to stop smoking. Two participants went ‘offlist’ so were lost to outcome follow up and another nine were lost to follow up due to non-response to mailshot, or having the wrong address noted on file at the practice. A further eight did not use their prescription, the main reason being that “the time wasn’t right” for them. 

 

For the main analysis purposes the sample size consisted of the 101 who used their prescription and completed follow up forms (40 males and 61 females). Initial motivation was found to be strong in male participants with 20 (50%) describing themselves as “very determined” to stop and 18 (45%) as “determined”, and two (5%) as “quite determined”. For females, initial motivation was even stronger, with 42 (68.9%) describing themselves as “very determined”, 15 (24.5%) as “determined”, and four (6.6%) as “quite determined”. Outcome in terms of smoking cessation was as follows: 35 (35%) smoked the same, 46 (45%) were smoking less and 20 (20%) had stopped. Figure 1 illustrates that gender distribution was very similar. 

 

For those who had managed to stop smoking with the help of NRT patches, the following reasons for their success were given in qualitative responses: 

 

It was apparent, therefore, that nearly half of those who had been successful felt that their own will power was a very important influence on outcome. It is also interesting to note that initial motivation was similarly distributed in all three outcome groups with 31 (89%) of those smoking the same, 45 (98%) of those smoking less and 19 (95%) of those who stopped describing themselves as either “very determined” or “determined” to stop. Although those smoking the same appeared to have very slightly less initial motivation to stop this was not statistically significant. 

 

Each factor was tested against smoking outcome using Spearman rank correlation, chi-squared test for trend and Kruskal-Wallis test. 

 

Length of time on NRT

The length of time patches were used indicated that those who used the patches for longer had more success than those who used them for four weeks or less and this was a highly significant finding (p<0.001). 

 

Age 

The mean age for males was 47 (range 17 – 71, s.d. 14) and for females 44 (range 17 – 73, s.d. 14). In terms of smoking outcome, older participants were more likely to have stopped or to be smoking less and this was a highly significant finding (p < 0.001). 

 

Health problems 

Data describing the health characteristics of the study group was compiled after careful scrutiny of each patient’s case notes. The following is an explanation of the various diagnostic categories: 

 

While all other diagnostic categories did not significantly influence smoking outcome, those who had a diagnosis of depression or anxiety tended to be still smoking the same or less (p < 0.05). 

 

Nicotine dependency 

Nicotine dependency (as assessed by the Fagerstrom Test) was similarly distributed in both sexes, with the majority (73, 72.3%, Fagerstrom score >=6) being highly nicotine dependent, 14 (13.9%,) having medium dependency Fagerstrom score =5 and 14 (13.9%) having low dependency (Fagerstrom <=4) but no association was found between nicotine dependency and outcome. Other variables examined in the study are reported on in descriptive fashion in Table I but similarly had no association with smoking outcomes. 

 

 

Summary 

Although several variables were considered in the study, those which significantly affected outcome were age, depression and length of time the patient used NRT. Older smokers tended to have more success in stopping or smoking less and similarly for those who used NRT for longer. Smokers have always cited smoking as being a form of emotional support 19, 20, 21 and it is perhaps not surprising, particularly in an area of socio-economic deprivation, that those who had a diagnosis of depression were less successful with smoking cessation in this study. 

 

Discussion 

Given that this study took place in a general practice population in an area that is noted as being socially and economically disadvantaged, the use of NRT patches had considerable success in that out of the 101 who used their prescription, 45% were smoking less and 20% had stopped. In addition, it was interesting to note that although the majority of the group (72%) were highly nicotine dependent, as assessed by the Fagerstrom Test,22 this did not impede smoking cessation success as no association was found between nicotine dependency and outcome. 

 

It must be acknowledged that a three month follow up is brief in terms of smoking cessation. However, with many of the group smoking less at the three month follow up stage, it is not unreasonable to expect that more people will eventually stop the longer they use NRT patches. This assumption is consistent with the Cochrane Review which based its findings on studies with follow up of at least six months.10 (Not surprisingly, in this study, it was a significant finding that those who used the patches for longer had considerably more success than those who used them for four weeks or less). Conversely, it must be acknowledged that although initial findings are encouraging, the nature of addiction is that relapse is likely to occur and that some of those who had stopped may well have resumed smoking once more.18 It is also recognised that cultural and environmental factors are likely to contribute to relapse. Nevertheless, it is encouraging to note that older smokers who, by definition, were likely to have had their habit for longer were more successful in stopping or smoking less. 

 

Although it must be acknowledged that a weakness in this study’s findings is that they are based on self-report smoking status, validity is gained through its findings being consistent with other studies 11, 12, 13 and it is a clear indicator that smoking cessation advice is not necessarily wasted on those who have had the habit for many years of their lives, with many being highly nicotine dependent, and should be encouraged in the general practice setting. The Coleman et al16 research indicated that many GPs discussed NRT with only a minority of smokers who might benefit from this therapy yet findings from our study suggest that a more proactive approach from the GP is clearly beneficial, particularly with older smokers. 

 

The lack of control groups can perhaps be seen as another limitation of the study but the researchers felt strongly that as the efficacy of NRT has been well-researched this was not necessary. The central aim of the study was not to show that NRT itself is effective but that encouraging GPs to take a proactive approach to prescribing is worthwhile, even in a deprived population which, by definition, has acknowledged difficulties in smoking cessation.3 

 

Lastly, if smoking is to be treated as an addiction by those who provide health care, then treatment should perhaps follow a more long term, gradual change model1 which, rather than emphasizing total abstinence as the immediate goal, encourages the use of maintenance patches. Acknowledging the relapsing nature of smoking cessation attempts (in this study group alone over 80% had made a previous attempt to stop and in over 40% of cases three or more attempts had been made), it is perhaps more realistic to have a step-by-step approach to abstinence. In addition, many (45%) were not able to achieve cessation at the three month stage but were smoking less. 

 

Many believe that smoking reduction rather than complete abstinence reduces the risk of smoking morbidity and mortality but the amount of risk reduction is difficult to quantify and as yet a definitive study has not been carried out. As Hughes24 states in his review of the evidence regarding the efficacy of smoking reduction "Reducing smoking does not appear to undermine cessation and may increase motivation for cessation." To date there have been no trials of smoking reduction which follow subjects for long periods of time. A general practice setting would be ideal to undertake this type of study. 

ACKNOWLEDGEMENTS: The authors would like to thank the partners and staff of Muirhouse Medical Group for their interest, help and support with this study and also to thank the patients for their participation and co-operation. They are also grateful to Lothian Primary Care NHS Trust for supporting this work. 

 

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