Tobacco smoking is the main preventable cause of morbidity and mortality in Australia. Recently published evidence-based guidelines for general practitioners recommend the 5As framework which is consistent with other international guidelines. Active follow-up of smokers by Quitline and the use of nurses to provide smoking cessation activities are two interventions that are likely to expand the reach of smoking cessation services and increase their effectiveness. Combination pharmacotherapies for nicotine dependence should be considered in smokers who have had difficulty quitting despite the concurrent use of brief behavioural counselling and pharmacotherapy.



Every year in Australia, tobacco smoking causes an estimated 19,000 deaths and up to 10% of hospital separations in people aged 35 years and over.1 The 50-year follow-up of the British doctors study shows that up to 66% of lifelong smokers are likely to die from a tobacco-related disease with half these deaths occurring prematurely.2 No other single avoidable factor accounts for such a high proportion of deaths.1

Health professionals have several strategies they can use to encourage patients to quit smoking. In addition to the publication of the first Australian smoking cessation guidelines for general practice in 2004,1 there have been a number of other developments. These include:

  • increasing evidence for the effectiveness of:
    - active callback programs by the Quitline3,4
    - nurses providing smoking cessation in the primary care setting5
  • the need to consider the use of combination pharmacotherapies in assisting smokers to quit.6

Smoking cessation guidelines for Australian general practice

The Australian general practice guidelines for smoking cessation follow the 5As framework (Table 1). To assist busy practitioners in summarising the effective smoking cessation activities a time-tiered synopsis of the 5As approach has also been published.* This intervention can be delivered in one minute or less.7

Table 1
5As smoking cessation framework*

5As Strategy Suggested approach

Ask Identify and document smoking status at least every 12 months Hand out brief patient survey in the waiting room to identify smoking status

Assess Interest in quitting How do you feel about your smoking at the moment?
How would you rate your interest in quitting right now on a scale of 1-10 where 10 equals very interested in quitting?
What do you like and dislike about smoking?

Barriers to quitting What would be the hardest thing about quitting?

Level of nicotine dependence Time to first cigarette from waking (less than 30 minutes)
Smokes 15 or more cigarettes a day
Evidence of withdrawal symptoms with previous quit attempts

Quitting history What has worked before?
What hasn't worked?

High risk situations What would be the hardest cigarette to give up?

Advise Provide clear, brief and non-judgemental advice to quit As your doctor, I strongly suggest that you stop smoking
Quitting is the most important thing you can do to stay healthy

Address the three domains Nicotine dependence
Psychological aspects of smoking

Assist Quit services Refer to Quitline 131 848
Offer Quit book
Enrol in Quitline callback program

Pharmacotherapy Discuss pharmacotherapy e.g. nicotine replacement therapies and bupropion

Address barriers to quitting Commonly:
- stress
- weight gain
- negative emotions
- lack of support
- fear of failure
- low self-confidence

Arrange Follow-up Review pharmacotherapy
Advise about relapse prevention
Review progress


Offer your support
Enlist support of significant others

* adapted from 'Smoking cessation guidelines for Australian general practice'1, GPs Assisting Smokers Program (GASP)7 and 'Treatment of tobacco use and dependence'9
in all states except Queensland

Active callback programs by telephone quit lines

Several recent randomised controlled trials in Australia and the USA have found an advantage in offering telephone follow-up to smokers referred to a quit line. Active follow-up (4-5 calls on average) in the first three months of quitting is associated with higher 12-month quit rates (between 22%3 and 25.8%4) than more passive referrals to the Quitline. This represents four more people quitting for every 100 counselled.


Nurse-delivered smoking cessation strategies

A systematic review has found that nurses have a similar impact to doctors when providing smoking cessation in primary care.5 The main findings of the systematic review were:

  • smokers offered advice by a nurse had an increased likelihood of quitting compared to smokers without nursing intervention (3-4 extra quitters for each 100 counselled)
  • smoking intervention in the 13 trials involving non-hospitalised adults gave an approximately 80% increase in the odds of success
  • there was no evidence from indirect comparisons that higher intensity interventions were more effective in achieving successful quitting.

Overall, the results revealed that brief smoking cessation interventions provided by nurses significantly increase the odds of quitting compared to usual care.


Combination pharmacotherapies in assisting smokers to quit

With the slow fall in the prevalence of smoking, the current population of smokers represent a mix of 'hardened' smokers who have attempted to quit on a number of occasions and others, for example younger smokers.8 Both groups are exposed to increasing community awareness of the harmful effects of smoking and expanding legislative changes to quit.

Identification of readiness to change, level of nicotine dependence and number of previous quit attempts will assist the practitioner in the approach to cessation, especially the use of pharmacotherapy.

Like other pharmacological treatments, combination therapy using drugs with different modes of action has been tried with differing degrees of success.6 Combination therapy can include two alternative forms of nicotine replacement therapy (NRT) or nicotine replacement and buproprion when 'the smoker has not been successful on an adequate trial of one of these therapies'. 1Most formulations of NRT provide doses of nicotine that are below that achieved by smoking.1 Combination NRT includes a formulation that provides basal levels of nicotine (for example nicotine patch) with 'top up' doses when withdrawal and craving are more likely to be a problem, for example first thing in the morning. Top up doses can be provided by a nicotine inhaler, lozenge or gum. Combination therapies should be considered in smokers who have failed despite behavioural intervention and a reasonable trial of a single formulation.

* A summary copy of the time-tiered 5As approach to smoking cessation can be found on the Cancer Council SA website[cited 2005 May 10]

Conflict of interest: none declared


Self-test questions

The following statements are either true or false.
Click anywhere on the panel for the answers.

1. Telephone follow-up by a quit line service increases the chance of a smoker successfully quitting smoking.

2. Patients should not use two forms of nicotine replacement therapy at the same time.

Answers to self-test questions

1. True

2. False


John Litt

Senior Lecturer in General Practice, School of Medicine, Flinders University, Adelaide