Andy McEwen

Smoking cessation activities by general practitioners and practice nurses

OBJECTIVES To assess general practitioners and practice nurses self reported behaviour, attitudes, and knowledge in relation to smoking cessation. DESIGN AND SETTING Two postal surveys of random national samples of 303 GPs (survey 1) and 459 practice nurses (survey 2) covering England and Wales; effective response rates were 75% and 96%, respectively. RESULTS Survey 1 found that 96% of GPs accepted that intervening against smoking was part of their role and almost all (99%) said that they recorded smoking status when patients registered; 57% reported that they routinely updated their records on smoking status, 50% said they advised smokers to stop during most or all consultations, and 76% said they advised smokers to cut down if they cannot stop. A large majority (83%) said they either recommended or prescribed nicotine replacement therapy (NRT). Although most GPs (86%) thought that NRTs were effective, only a minority thought they were worth the cost (47%) or should be on National Health Service (NHS) prescription (32%). There was little evidence that previous training in smoking cessation was associated with more activity, more positive attitudes, or greater knowledge. Survey 2 found that almost all practice nurses (99%) agreed that intervening against smoking was part of their role and 95% said they advised patients to stop at least occasionally; 71% said they advised smokers to stop at most or all consultations. A majority (74%) said that they recommended NRT to their patients. As with the GPs most practice nurses thought that nicotine replacement was effective (79%), but fewer (42%) thought the cost was justified, and only about half (53%) thought it should be available on NHS prescription. Nurses who said they had been trained in smoking cessation engaged in more activity relating to smoking cessation, had more positive attitudes, and were more knowledgeable. CONCLUSION GPs and practice nurses accepted that intervening with smoking was an important part of their role and a large majority reported that they intervened at least with some smokers. This represents a promising baseline from which to proceed in terms of implementation of the new smoking cessation guidelines, but it is hoped that improvements can be made in terms of the frequency of updating records and intervening, and acceptance of the cost-effectiveness of NRT as a life preserving intervention.

Increase in common cold symptoms and mouth ulcers following smoking cessation

Objective: To examine changes in reports of common cold symptoms and mouth ulcers following smoking cessation. It was hypothesised that reports of these symptoms would increase on stopping smoking. Design: Smokers were assessed one week before stopping smoking (baseline), then after one, two, and six weeks of smoking abstinence. Participants: 174 smokers attending a seven week smoking cessation programme combining behavioural support with nicotine patches. Main outcome measures: Self reports of cold symptoms, mouth ulcers, and smoking abstinence (validated using expired carbon monoxide) were recorded on each measurement occasion. Results: Following one, two, and six weeks of smoking abstinence 73.0% (127/174), 57.5% (100/174), and 44.8% (78/174) of the participants, respectively, maintained continuous abstinence and provided reports of cold symptoms and mouth ulcers. For those abstinent from smoking for six weeks, relative to baseline, a significant increase in reports of the number of cold symptoms was observed following one and two weeks of smoking abstinence (p = 0.009 and p = 0.038, respectively) and an increase in reports of mouth ulcers after one and two weeks of abstinence (p = 0.004 and p = 0.008, respectively). Following one week of abstinence significant increases in reports of sore throat, coughing, deafness, and sneezing were observed (p = 0.049, p < 0.001, p< 0.039, and p < 0.003, respectively). Conclusions: This is the first study to systematically document significant increases in cold symptoms and mouth ulcers following smoking cessation. Smokers should be informed that they have an increased chance of experiencing these symptoms on stopping smoking. Being psychologically prepared for these effects may reduce their impact on the attempt to stop smoking.

General Practitioners' views on the provision of nicotine replacement therapy and bupropion

BackgroundNicotine replacement therapies (NRT) and a new drug, bupropion, are licensed in several countries as aids to smoking cessation. General practitioners (GPs) play a crucial role in recommending or prescribing these medications. In the UK there has been discussion about whether the medications should be reimbursable by the National Health Service (NHS). This study assessed English GPs attitudes towards reimbursement of NRT and bupropion.MethodsPostal survey of a randomly selected national sample of GPs; 376 GPs completed the questionnaire after one reminder; effective response rate: 53%. There was no difference between the responses of GPs who responded to the initial request and those who responded only after a reminder suggesting minimal bias due to non-response.ResultsAttitudes of GPs were remarkably divided on most issues relating to the medications. Forty-three percent thought that bupropion should not be on NHS prescription while 42% thought that it should be (15% did not know); Fifty percent thought that NRT should not be on NHS prescription while 42% thought it should be (8% did not know). Requiring that smokers attend behavioural support programmes to be eligible to receive the medications on NHS prescription made no appreciable difference to the GPs views. GPs were similarly divided on whether having the medications reimbursable would add unacceptably to their workload or offer a welcome opportunity to discuss smoking with their patients. A principal components analysis of responses to the individual questions on NRT and bupropion revealed that GPs attitudes could be understood in terms of a single pro-con dimension accounting for 53% of the total variance which made no distinction between the two medications.ConclusionsGPs in England appear to be divided in their attitudes to medications to aid smoking cessation and appear not to discriminate in their views between different types of medication or different aspects of their use. This suggests that their attitudes are generated by quite fundamental values. Addressing these values may be important in encouraging GPs to adhere more closely to national and international guidelines.

Answers to Multiple Choice Questions

Unlike theWest where antibiotics are themost common cause of drug-induced liver injury (DILI) and paracetamol (acetaminophen) is the most common cause of acute liver failure (ALF), antitubercular drugs are the most common cause of both DILI and ALF in India. The degree of elevation of liver enzymes correlates poorly with severity of liver injury, but presence of clinical jaundice is a strong predictor of mortality, called the Hys law. Hys law has been now been modified by the Food and Drug Agency as bilirubin >2 mg/dL or and transaminases >3 upper limit of normal. The pattern of liver injury also dictates the outcomes, with cholestatic DILI having better prognosis than hepatocellular DILI, but with higher chance of protracted course, despite stopping the offending drug.