Smoking and smoking cessation

Recommendations:
the current smoking status of all patients should be known (C) patients who smoke should be advised to stop (C) there is no one strategy that is effective for all patients (C)

advice and strategies should be tailored to individual circumstances (C)

patients should avoid passive smoking (C)

One meta-analysis (Silagy et al. 1994) and one systematic review (Tang et al. 1994) of nicotine replacement were identified within the search. The meta-analysis identified methodological concerns about the 53 studies that it included though it concluded that if using nicotine replacement the odds ratio for abstinence was 1.7. The systematic review concluded that intervention with nicotine replacement therapy could enable 15% of smokers to stop.

References

Silagy, C., Mant, D., Fowler, G. and Lodge, M. (1994) Meta-analysis on efficacy of nicotine replacement therapies in smoking cessation. Lancet 343:139-142.

Tang, J.L., Law, M. and Wald, N. (1994) How effective is nicotine replacement therapy in helping people to stop smoking? British Medical Journal 308:21-26.

Patient education

Recommendation:

patients should be offered education about their condition and its management. The studies reviewed are such that it is not possible to draw out common successful strategies (C)

Statement: patient education is capable of improving knowledge and beneficially altering behaviour (I).

Comment:

Patient education, within the context of controlled evaluations, is capable of improving knowledge and beneficially altering behaviour. Four of the six studies demonstrate this. Of the two that did not one was principally looking at improving knowledge only. The study designs are such that it is not possible to draw out common successful strategies. However, the largest study, a Scotland-based pragmatic randomised controlled trial showed only limited benefit in one sub-group of patients from the use of printed information.

Hilton et al. (1986) studied 339 patients in a systematically allocated open study (the interviewers assessing the intervention were blinded to allocation). The interventions were a maximum education programme, a limited education programme, and no intervention. Improvement in knowledge was shown for the maximum intervention group but no group showed any change in self-management ability. All groups showed improvement in asthma morbidity.

Jenkinson et al. (1988) studied within a randomised study intervention with a book, a tape, both a book and a tape, or neither. After 12 months the intervention of the tape or the book and the tape increased knowledge scores over the book alone and no intervention. There were no changes in inhaler skills, morbidity diary, drug usage or consultation rate.

Bailey et al. (1990) studied 267 patients in a randomised open study of usual care or a comprehensive programme that integrated a work book with one to one counselling and adherence enhancing strategies. The intervention produced improvement in inhaler skills and adherence, medication adherence, staff assessment of performance, severe symptoms in the seven days preceding the final assessment and similarly episodes of asthma in the last three months.

Windsor et al. (1990) studied 267 patients in a randomised open study of the effectiveness of a health education intervention consisting of a 30 minute one to one session, and use of self-help guide to asthma control, a 60 minute support group session and two brief telephone reinforcement calls. Over a 12 month period the intervention group had improved inhaler use and adherence, medication adherence, and a total adherence rating.

Wilson et al. (1993) studied 323 patients in a "blocked" randomised study of four groups comprising small group education, individual teaching, a workbook control group, and a no intervention control group. There were no consistent patterns from the three intervention groups. The largest significant effects demonstrated were in environmental control in the bedroom and changes in inhaler technique. There were a number of other significant differences between differing groups but there was no consistent pattern for the effectiveness of any one intervention.

Osman et al. (1994) studied, within a pragmatic randomised trial, 801 adult patients who took part in an enhanced education programme (four personalised booklets sent by post) or received conventional oral education at out-patient or surgery visits. In the intervention group the more severe patients had a significant reduction in hospital admissions as did the rest of the intervention group when allowance for not spending a full 12 months period in the study was allowed for. Sleep variation was also lower in the intervention group. There was no significant difference in days of restricted activity, prescribed bronchodilators or inhaled steroids, use of oral steroids, or number of general practitioner consultations.

References

Bailey, W.C., Richards, J.M., Jr., Brooks, C.M., Soong, S.J., Windsor, R.A. and Manzella, B.A. (1990) A randomized trial to improve self-management practices of adults with asthma. Archives of Internal Medicine 150:1664-1668.

Hilton, S., Sibbald, B., Anderson, H.R. and Freeling, P. (1986) Controlled evaluation of the effects of patient education on asthma morbidity in general practice. Lancet i:26-29.

Jenkinson, D., Davison, J., Jones, S. and Hawtin, P. (1988) Comparison of effects of self-management booklet and audiocassette for patients with asthma. British Medical Journal 297:267-270.

Osman, L.M., Abdalla, M.I., Beattie, J.A.G., Ross, S.J., Russell, I.T., Friend, J.A., et al. (1994) Reducing hospital admission through computer supported education for asthma patients. British Medical Journal 308:568-571.

Wilson, S.R., German, D.F., Lulla, S., Chardon, L., Starr-Scheidkraut, N. and Arsham, G.M. (1993) A controlled trial of two forms of self-management education for adults with asthma. American Journal of Medicine 94:564-576.

Windsor, R.A., Bailey, W.C., Richards, J.M., Manzella, B., Soong, S. and Brooks, M. (1990) Evaluation of the efficacy and cost effectiveness of health education methods to increase medication adherence among adults with asthma. American Journal of Public Health 80:1519-1521.

Research questions

The effect of patient education on behaviour needs to be evaluated in a pragmatic community based randomised controlled trial.

Referral

Comment:

We could identify no evidence concerning the referral of patients with asthma, either from primary to secondary care or between health care professionals within primary care. These recommendations are taken from the British Thoracic Society guidelines.

Referral to a chest physician

Recommendation:

• referral to a respiratory physician is appropriate for:
  • (1) patients in whom there is diagnostic doubt
  • (2) patients with possible occupational asthma
  • (3) patients who present a problem in management (C)

Diagnostic doubt would apply to patients such as the elderly and smokers with wheeze in whom the diagnosis may be difficult; those with unexplained persistent cough; and those with systemic symptoms (for instance, fever, rash, weight loss or proteinuria) that might suggest associated disorders such as systemic eosinophilia or vasculitis.

Patients with management problems would include those with catastrophic sudden, severe brittle asthma; those with continuing symptoms despite high doses of inhaled steroids; those being considered for long-term treatment with nebulised bronchodilators; pregnant women with worsening asthma; patients whose asthma is interfering with their lifestyle despite changes in treatment; and patients who have recently been discharged from hospital.

Comment:

The consensus group made additional points of clarification:

Recommendation:

• occupational asthma should be referred for the confirmation of the diagnosis, the management of sensitiser avoidance and the management of other workers in the workplace (C)

  Comment:While this could be managed by general practitioners the low prevalence of such patients in the population means that any one general practitioner will have only limited experience in their management.

• patients whom a general practitioner is considering for long term oral steroids or home use of a nebuliser should be referred to a respiratory physician for assessment (C)
• patients who have recently been discharged from hospital should have their treatment reviewed; this does not need hospital review if the primary health care professional possess the relevant skills and resources (C)
• patient preference should be accommodated in the decision to refer (C)
• primary health care professionals should be aware of the range of skills and facilities available within their practice and should, when appropriate, refer within the practice (C)