Tobacco use is the single most preventable cause of ill-health and premature death in Scotland and a major cause of inequalities in health (Crossan & Amos 1994). In Scotland 13,000 people die every year from tobacco-related diseases (Callum 1998). Recent evidence has also confirmed the serious health risks of passive smoking: non-smokers exposed to environmental tobacco smoke have a 23% greater risk of developing heart disease (Law, Morris & Wald 1997) and a 26% greater risk of lung cancer (Hackshaw, Law & Wald 1997). With the Government committed to implementing a tobacco control strategy via a forthcoming White Paper and having signed up to the EU Directive banning tobacco advertising, the time is opportune to focus on smoking cessation interventions. The government has set targets to reduce the levels of smoking by the year 2000. 'Scotland's Health - A Challenge to Us All' aims for a 30% reduction in the number of smokers aged 12-24 years between 1986-2000 and a 20% reduction in the number of smokers aged 25-65 years over the same time period. Although there has been a significant fall in the number of adult smokers over the last 10 years, there has been little progress toward meeting the target for young people (Bennet et al 1996). Indeed, latest figures show that in Scotland the numbers of smokers aged under 16 years is increasing (Barton & Jarvis 1997). Results from the 1996 General Household Survey also give cause for concern about adult smoking rates. Preliminary figures indicate that in Great Britain the prevalence of smoking amongst adult men increased from 28% in 1994 to 29% in 1996 and amongst adult women from 26% to 28% (Office of National Statistics 1997). In addition, the 1995 Scottish Health Survey found that 35% of Scottish adults smoke cigarettes, representing more than 1 in 3 of the adult population.
Whilst tobacco use has halved among better off families in Britain those living in the most deprived circumstances have continued to smoke at the same high rates as in the 1970s. An increase in income inequalities, particularly among families, combined with a rapid growth in lone parenthood, has created a closer and closer association between tobacco use and poverty. The disadvantage, inequality and hardship experienced by low income parents causes them to be much more likely to smoke compared with other, better-off, families. The 1995 Scottish Health Survey confirms that those in the less well-off classes are more likely both to smoke cigarettes and to smoke more cigarettes per day. Fifty five percent of men and women in social class V smoke compared with 15% in social class I (Dong & Erens 1997).
The NHS in Scotland spends an estimated £140 million on hospital treatment for diseases caused by smoking (Buck et al 1997). Reducing smoking will lead to health gains which will in the long term reduce smoking related health care costs. Few medical interventions of any kind have the potential of smoking cessation to deliver such cost-effective health gains (Buck 1997).
Despite this, compared with treatment services for other addictions, there is a marked absence of provision of specialist smoking cessation services to meet the needs of people who smoke. However, the majority of smokers still want to stop. West estimates that 67% of Scottish smokers want to give up (West 1995) but the success rate for 'self-quitters' is low. The 1-year continuous abstinence rate for smokers making an unaided quit attempt is less than 5% (Foulds 1996). Primary care professionals are, therefore, uniquely placed to assist patients who smoke. However, to date much of the potential input which primary care professionals can have has not been realised.
A considerable amount of evidence about the efficacy of smoking cessation interventions has accumulated from randomised controlled trials (RCTs) conducted in specialist clinics and in primary care. Following a systematic review of this evidence, the US Agency for Health Care Policy and Research (AHCPR) AAHCP in has proposed a 'stepped care' approach to smoking cessation. This involves the provision of brief, low cost interventions for smokers who can stop without extensive support, moving up to provision of specialist smoking cessation clinics for the most dependent smokers. The AHCPR has recommended a set of protocols for maximising the effectiveness of smoking cessation interventions (AHCPR 1996) (Appendix One). An effective stepped care approach could also be adopted in Scotland which would ensure that the intensity of the intervention is matched to the smoker's levels of motivation and addiction (Appendix Two).
The following discussion is based on evidence presented in a range of systematic reviews of the effectiveness of smoking cessation interventions and the contributions made by members of the ASH Scotland/HEBS expert working group (Appendix Three).