An MBS item to counsel smokers? It's just a load of smoke

 Tobacco smoking remains prevalent in Australia – current estimates suggest that we have about two million adult smokers.

This number has fallen in recent decades as the enormity of problems associated with smoking have become clearer.

Nevertheless, according to analyses from the Australian Institute of Health and Welfare in 2019, the proportion of pack-a-day (20 cigarettes or more) smokers increased with age.¹

Two in five people (approximately 40%) in age groups 40 and over smoked more than 20 cigarettes per day, which compared to one in five (approximately 20%) people aged 18–39. It’s ironic that smoking is more prevalent among older people at higher risk of tobacco-induced death.

 

Public health-based approaches, such as tobacco taxes underpinning massive price hikes, banning the advertising of tobacco, either directly or indirectly with zero investment in sports sponsorship since 1992, have combined with clinical counselling for smokers to cause smoking to become far less common.

But we have a long way to go.

While tobacco taxes are considered the most effective tool to reduce smoking, clinical approaches and counselling have gained in sophistication and impact, sometimes using nicotine replacement preparations in concert with advice. 

The late Dr Michael Russell, a psychiatrist with a major interest in addiction, and three colleagues including a GP, published a paper in the BMJ in 1979 that reported attempts to get 2000 established smokers in London to quit. It caused a storm.²

The study was based on the patients of 28 GPs.

The smokers were allocated into four groups; a non-intervention group, a group that was given a questionnaire about smoking, a third group that was advised by their GP to stop smoking (but nothing else was done) and a fourth group who were advised to stop smoking, given a leaflet to help them, and warned that they would be followed-up.

The effects were small with 5.1% of those in group four – who received advice, literature and follow-up – stopping smoking in the first month and still not smoking after a year.  

But here is the crucial sentence taken from the abstract of their BMJ paper: “[The results were] achieved by motivating more people to try to stop smoking rather than increasing the success rate among those who did try.”

Earlier this month, the Federal Department of Health proposed a Medicare item to fund at least 20 minutes of smoking cessation counselling with a GP, who will then be tasked with drawing up a management plan.

The health department says a dedicated item will help GPs become more familiar with updates to clinical smoking cessation guidelines and their use.

However, such an approach assumes the intervening GP knows that a patient of theirs is a smoker – but if they don’t they’re unlikely to act. 

That sounds miserable, but studies by Professor James Dickisnon and colleagues from Newcastle published in the Medical Journal of Australia have shown that between 20% and 40% of smokers presenting in general practice are not known by their GPs to be smokers.³

It is these ‘quiet Australians’ that Dr Russell and his team would have us recognise, and try to help, rather than bothering with identified smokers who make no progress, despite us spending lots of resources attempting to get them to quit.

Read more:

• Are PBS rules hampering smoking cessation?
• Another new MBS item for GP care, but will it help?

I know this proposition will not find favour with dedicated educators and clinicians who have spent much personal energy developing packages to assist practitioners counsel established smokers.

There is no reason for such efforts to be ignored or undervalued, save for the question – are we spending the health dollar wisely?  

If a Medicare item encourages a 20 minute counselling approach to smoking cessation, then the dollar won’t be available for Dr Russell-type approaches.

He argued that the success of ultra-simple interventions in general practice would see 25 long-term successes per GP every year. And if all 20,000 GPs in Britain (in 1979) adopted it, 500,000 smokers would be helped to quit in one year.

No fuss, no bother, inexpensive and time efficient.

This result would be better, Dr Russell said, than what could be achieved by setting up “10,000 smoking withdrawal clinics” a year to manage difficult and dependent patients, often with little chance of successful quitting. 

“GPs, on the other hand, see all kinds of smokers, including those who are more likely to succeed and will not necessarily need intensive treatment and support. Firm advice to stop smoking, without any accompanying treatment or support, may be as effective as protracted treatment at special withdrawal clinics,” the researchers wrote.

The fundamental point at issue is whether supporting 20-minute consultations for quitting is a wise use of public money.  

I do not believe it is when the alternative is supporting GPs to provide economical and brief support to all the smokers they encounter in their daily practice.

Acknowledgement: I am grateful to my colleague Professor Simon Chapman, emeritus professor in public health at the University of Sydney, for his comments.

References:

1.       AIHW 2020; National Drug Strategy Household Survey 2019  

2.       Br Med J. 1979 Jul 28; 2(6184): 231–235)

3.       MJA 1989 Apr 17;150(8):420-2, 425-6.

Published in Medical Observer Opinion
21st June 2021