30 seconds to save a life: Very Brief Counselling

The evidence is clear: physicians can increase the likelihood of their patients’ smoking cessation by 25%.^1,2 In fact, a meta-analysis of the effectiveness of physician advice to quit smoking found that clinical Intervention of three minutes or less significantly increased both cessation and long-term abstinence (Table 1).² And with a number needed to treat (NNT) of just 9 (based on a 45-year-old woman), it’s clear that smoking cessation is a key factor In relative risk reductlon.³ (In comparison, lipid-lowering has an NNT of 34.)

Table 1. Effectiveness of physician advice to quit and estimated abstinence rate²

CI = confidence interval

What is Very Brief Counselling?

As its name suggests, Very Brief Counselling is short advice (less than three minutes) for all patients who smoke, regardless of their current motivation level to quit. It consists of three steps:

Step 1: Ask

Step 2: Advise

Step 3: Act

The last step is the most important – offer action, particularly if it can be done in the practice setting. Patients can be referred to a smoking clinic, group counselling, or a telephone quit line; they can also be made aware of the numerous smoking cessation websites and resources that are available on the internet.

Many patients respond positively to an offer of help, even those who were not thinking of making a quit attempt.⁴ If possible, consider following up with telephone support. It has been found to increase cessation rates by up to 50%.⁵

The Three Steps of Very Brief Counselling

Step 1: Ask

• Have you used any tobacco products in the past week/month/3 months?

Step 2: Advise

• Offer advice in an encouraging, supportive, empathetic manner
• Advise that best results typically are achieved with pharmacotherapy and support

Step 3: Act

• Refer to counselling, internet programs, telephone quit lines
• Consider first-line smoking cessation medications, which include nicotine replacement therapy, bupropion and varenicline⁶

Smoking cessation medications can double to triple the likelihood of quitting success over placebo.² Health Canada recommends that nicotine replacement therapy be tried before bupropion or varenicline.⁷ Combination therapy may be necessary for successful cessation in some patients.^8–10

A shared responsibility

As a group, healthcare professionals (HCPs) represent a powerful force for influence. The likelihood of quitting increases when a smoker hears the message from more than one HCP.¹¹

From physicians, to nurses, nurse practitioners, to pharmacists, the degree to which healthcare professionals can echo the advice to quit and offer support, is a very powerful message to smokers. The majority of Canadians consult an HCP at least once a year,¹² creating teachable moments when they may be more receptive to advice regarding changing unhealthy behaviour.¹³

Not only can routine advice from a primary practitioner have a positive impact on long-term cessation, but smokers who are advised by their doctor to quit are almost twice as likely to do so than those who are not.¹⁴

The time to act is now

From general practitioners to emergency department personnel, Very Brief Counselling is easy to integrate into every patient interaction, regardless of the health reason for the visit. By adopting Very Brief Counselling across the healthcare profession and incorporating it at every touch point –not just when patients bring up quitting or when a comorbidity makes it essential to raise the issue – countless lives will be saved.

Overcoming barriers to advice

Despite the evidence of its positive effect, only 50% of patients (in the US) receive advice to quit from their general practitioners.¹⁵ Why aren't more HCPs encouraging smoking cessation?

Barriers include:

• Lack of education: HCPs may not know how to identify smokers or may be unfamiliar with the many different types of treatments available, form psychological to pharmaceutical. Many clinicians cling to outdated concepts regarding smoking and cessation.
• Lack of time or skills: HCPs may feel they don't have adequate training in cessation counselling or feel that it would place an even greater burden on their schedule.
• Misunderstanding of the quit journey. Relapses can be frustrating for both patients and HCPs alike. Yet, relapses are common on this difficult journey, making HCP support for the smoker even more important.
• Perception of inefficiency or lack of patient motivation. Some HCPs may think that counselling doesn't work or that their patients simply don't want to quit.
• Reluctance to raise a sensitive issue with the patient. The topic of quitting may be a difficult one to broach with some patients.

Very Brief Counselling may help overcome these barriers. It provides an easy, effective way to counsel smokers to quit in as little as 30 seconds.

9 key recommendations for treating tobacco use and dependence

The US Department of Health and Human Services offers a guideline for HCPs on effective ways to treat tobacco use and dependence:²

1. Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit.
2. It is essential that physicians and allied health professionals consistently identify and document tobacco use status and treat every tobacco user seen in a healthcare setting.
3. Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt or reduction.
4. Brief tobacco dependence counselling is effective. Clinicians should offer every patient who uses tobacco at least a brief intervention.
5. Individual, group and telephone counselling are effective and their effectiveness increases with intensity.
6. Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking – except when medically contraindicated.
7. The combination of counselling and medication is more effective for treating tobacco dependence than the use of either alone.
8. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use motivational interviewing techniques to encourage future quit attempts.
9. Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders.

References

1. West R. Enhancing Motivation to Stop Smoking: From Theory to Practice. London, UK: University College London; 2014. Available at: http://www.slideshare.net/GeorgiDaskalov/31-c5-motivaciondeteoriaapracticarwest. Accessed April 6, 2016.
2. US Department of Health & Human Services. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: Agency for Healthcare Research and Quality. Available at: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html. Accessed April 6, 2016.
3. Woolf SH. The need for perspective in evidence-based medicine. 1999;282:2358–2365.
4. Aveyard B, Begh R, Parsons A, et al. Brief opportunities for smoking cessation interventions: a systematic review and meta-analysis to compare advise to quit and offer of cessation. Addiction. 2012;107(60):1066–1073.
5. Stead LF, Hartmann-Boyce J, Perera R, et al. Telephone counselling for smoking cessation. Cochrane Database Sys Rev. 2013;8:CD02850.
6. Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Sys Rev. 2008;1:CD000146.
7. Government of Canada website. Public Communication – Health Canada Endorsed Important Safety Information on CHAMPIX (varenicline tartrate) and ZYBAN (bupropion hydrochloride). Available at: http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2013/33623a-eng.php. Accessed April 6, 2016.
8. Issa JS, Abe TO, Moura S, et al. Effectiveness of coadministration of varenicline, bupropion, and serotonin reuptake inhibitors in a smoking cessation program in the real-life setting. Nicotine Tob Res. 2013;15:1146–1150.
9. Ebbert JO, Burke MV, Hays JT, et al. Combination treatment with varenicline and nicotine replacement therapy. Nicotine Tob Res. 2009;11:572–576.
10. Ebbert JO, Hatsukami DK, Croghan IT, et al. Combination varenicline and bupropion SR for tobacco-dependence treatment in cigarette smokers: a randomized trial. JAMA. 2014;311:155–163.
11. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2008;2:CD000165.
12. Nabalamba A, Millar WJ. Going to the doctor. Health Rep. 2007;18(1):23–35.
13. Canadian Medical Association. Tobacco Control (2008 Update). Available at: https://www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Tobacco_Control_Update_2008_PD08-08-e.pdf. Accessed April 6, 2016.
14. Hughes JR. Motivating and helping smokers to stop smoking. J Gen Intern Med. 2003;18(12):1053–1057.
15. Danesh D, Peskett ED, , Ferketich AK, et al. Disparities in receipt of advice to quit smoking from health care providers: 2010 National Health Interview Survey. Prev Chronic Dis. 2014;11:E131.