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EDITORIALS: Sean P David and Marcus R Munafò Smoking cessation in primary care BMJ 2008; 336: 1200-1201 [Full text]

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BETTER SMOKING IN PRIMARY CARE

GEORGE Y CALDWELL, SINGAPORE 259858   (17 May 2008)

What about children who smoke?

Andrew S Furber   (30 May 2008)

The Academic Cart is before the Practice Horse

Andrew J Ashworth   (31 May 2008)

BETTER SMOKING IN PRIMARY CARE 17 May 2008
GEORGE Y CALDWELL, GENERAL PRACTITIONER 31 BALMORAL PARK, #18-33,, SINGAPORE 259858 Send response to journal: Re: BETTER SMOKING IN PRIMARY CARE	That doctor, Sir Richard Doll, who told us all to stop smoking also declared that SECOND HAND SMOKE KILLS NO-ONE. It is certainly just bad manners and selfish to smoke in the presence of children. If you can't give up the habit, since it is the Nicotine in "quick- dried" tobacco which is the harmful artery-narrowing and skin-shrinking agent, then it would be better to smoke "slowly- dried" i.e. local tobacco, present in certain cigarettes like Egyptian and Turkish, Philipino and Indonesian, and good Cuban cigars. Quick kiln-dried tobacco (B.A.T. etc.) retains 90% of the Nicotine. Peasant-grown and slow-dried, in open sheds under thatched roofs, with the wind blowing through the leaves, the tobacco loses most of its Nicotine and tastes and smells so different. Competing interests: None declared
What about children who smoke? 30 May 2008
Andrew S Furber, Director of Public Health North Lincolnshire Primary Care Trust Send response to journal: Re: What about children who smoke?	More excellent research and analysis on smoking in adults. But as World No Tobacco Day on 31 May 2008 looks at helping children and young people say no to tobacco, it is clear that we need more research and analysis on effective interventions before people reach adulthood. Forthcoming National Institute for Health and Clinical Excellence (NICE) guidance on 'Preventing the Uptake of Smoking by Children' will be welcome, but its recommendations are likely to rely on research conducted outside the UK. In terms of helping young smokers to quit, we know that effective programmes for adults (probably including the intervention described by Aveyard et al.) are ineffective for young people. As a Director of Public Health I regularly receive requests from schools for support to help young smokers quit. Whilst I offer support around prevention, until I know what works to help children quit there is little else I can do. Competing interests: None declared
The Academic Cart is before the Practice Horse 31 May 2008
Andrew J Ashworth, GP Davidson's Mains Medical Centre, 5 Quality Street, Edinburgh, EH4 5BP Send response to journal: Re: The Academic Cart is before the Practice Horse	The authors rightly point out that “The pragmatic approach (to research) may make doctors more confident that they can generalise results to real world practice” but, as a real world practitioner, I need research to answer my pragmatic questions for my real patients. In the field of smoking cessation, even assuming that the patient is motivated at ready to change, I want to know: a) What product will reduce withdrawal symptoms and cravings adequately for this individual? b) What starting dose will produce the best long term outcomes? c) What rate of dose reduction is appropriate for this individual? d) How long should treatment continue? Research published in this week’s journal (1)looks at 901 people who are “trying to stop smoking” (defined as “attending a smoking cessation service”). This adds another question for me as a GP: e) Who should I treat myself and who should I refer? Smoking cessation is a measure of behavioural output rather than medical outcome. If my argument to the patient is that smoking makes them unhealthy then I need direct evidence that my intervention will affect their health, for their disease. For example, in COPD I have evidence that those who are able to stop smoking using current methods (including willpower) will reduce disease progression but I do not know how to manage those who cannot stop (about half of both groups were smoking at 4 weeks in Aveyard et al’s study). If I give long term nicotine replacement and my patient still has a few cigarettes, making her a “failure” in research terms will she be healthier for longer? Will a course of the latest expensive pharmaceutical smoking cessation product now save later on expensive bronchodilator drugs? We pragmatists in the real world need our questions answered by our academic colleagues. We are offered definitive answers to questions we have not asked and so are invited to guess how those answers might apply to the questions we need to answer: at the moment the academic cart is before the practice horse. Qualitative studies of real world ambiguities in practice are needed to set the questions for definitive quantitative research. The BMJ might consider encouraging such a pragmatic "real world" approach by commisioning qualitative research into the questions asked by clinicians and thus set the agenda for meaningful research that makes a significant difference to outcomes in practice. 1. Nortyptyline plus nicotine replacement versus placebo plus nicotine replacement for smoking cessation: pragmatic radomised controllled trial Aveyard P et al. BMJ 2008;336:1223-7 Competing interests: None declared