Practice nurses and the

prevention of cardiovascular disease and stroke: a literature review to promote evidence-based practice. Pact I: rationale review methods, effectiveness of practice nurses and smoking cessation 9

A. McDonnell, P. Crookes, S. Davies and J. Shewan

Ann McDonnell NSc, BSc, RGN, RN~ Lecturer in Nursing, School of Nursing and Midwifery, University of Sheffield, UK Patrick Crookes PhD. BSc, RGN, Cert Ed, Senior Lecturer, University of \Nollongong, Australia Sue Davies NSc BSc, RGN, RHV, Lecturer in Nursing, School of Nursing and Nidwifery, University of Sheffield, UK Jane Shewan BEd,RGN Staff Nurse, Bar-nsley District General Hospital, UK Correspondence to: Ann NcDonnell, University of Sheffield, School of Nursing & Hidwifery, Samuel fox House, Northern General Hospital, Herries Road, Sheffield SS 7AU, UK E mail: ,mlcdon [email protected] Tel: 0114 271406

This paper is the first in a series of two which together describe a review of current literature conducted to identify a range of research-based activities which practice nurses might employ in the primary and secondary prevention of cardiovascular disease ( C V D ) and stroke.The paper first describes the rationale for the review, methods and boundaries of the review and provides an overview of the research into the general effectiveness of practice nurses in the field of C V D and stroke prevention. Risk factors for C V D and stroke are then discussed, with particular emphasis on: 9 9

smoking and C V D risk smoking cessation and C V D risk.

Specific primary care interventions aimed at helping clients to stop smoking are then examined under the following headings: 9

9

GPs and smoking cessation brief advice brief advice combined with nicotine substitution Practice nurses and smoking cessation.

T h e paper concludes with a list of research-based activities for practice nurses in relation to smoking cessation. Interventions relating to hypertension, raised blood cholesterol, lack of exercise and obesity are considered in a subsequent paper. Keywords: practice nurses, cardiovascular disease, effectiveness, smoking

Clinical Effectiveness in Nursing (1997) I, 189 1979 1997 HarcourtBrace& Co. Ltd

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R A T I O N A L E : T H E I M P O R T A N C E OF PREVENTING CVD AND STROKE IN P R I M A R Y C A R E Cardiovascular disease (CVD) remains the leading cause of death in the UK and in 1990 accounted for nearly 170,000 deaths (27% of annual mortality for all cases) (DOH 1994a). The scale of the impact of CVD on individual health is demonstrated by a recent technical review document which estimates that around 2% of adults in the UK have CVDrelated disability (Trent Health 1993). The actual monetary costs of the resources used to prevent and treat CVD are substantial. It is estimated that in 1989/90 CVD attracted approximately 4% of total NHS expenditure in England excluding Community Health Services (DOH 1994a). Nationally, the cost of treating CVD has been estimated at s million per a n n u m - s per capita at 1992 prices (Langham 1995). Within the primary care sector, the costs of CVD prevention have risen sharply over the last 5 years. The 1990 GP contract introduced a system of payments for health checks carried out in clinics, and by 1992-93 the annual costs reached s million (Cook 1995). Since much of this work could be carried out by practice nurses, this initiative is also believed to account for the substantial increase in practice nurse posts during this period (Robinson & Robinson 1993). Following the introduction of health promotion bandings in 1993, GP payments were based on a banded structure of health promotion activities designed to reduce CVD and stroke which has contributed to a further increase in costs. As improved treatments become available and patients live longer, the prevalence of CVD may remain relatively high, even as incidence falls. Experience in the USA has shown that this is unlikely to result in a reduction in costs. In the long term, the only way to reduce costs or even to slow the increase in costs, is to make efforts to decrease the incidence of CVD by addressing the underlying risk factors (Langham 1995). There is abundant evidence to show that CVD and stroke are associated with preventable risk factors (DOH 1994). Some of these risk factors (such as age and family history) clearly cannot be changed by individuals. Others, such as smoking, diet, and lack of exercise can be modified and there is a growing body of research to suggest that, if risk factor modification is achieved, it results in significant reductions in the mortality and morbidity associated with CVD and stroke (DOH 1993b). Achievement of objectives in the Key Area of CVD and stroke is likely to have the biggest impact of all the Health of the Nation targets (DOH 1992). The 1990 revised GP contracts and the health promotion banding system introduced in 1993 were the focus of attempts to achieve these targets through structural changes within primary health care.

A number of guides have been developed by expert working groups to assist primary care teams to reduce the risk of CVD and stroke in their practice populations through the promotion of lifestyle changes (for example, DOH 1993a). These resources draw together the available evidence to support specific interventions in the following areas: 9 9 9 9 9 9

assessing and monitoring of risk factors; stopping smoking; maintaining an adequate level of physical activity; eating a healthy diet; maintaining alcohol consumption within 'sensible' limits; detecting and treating hypertension.

These interventions form the focus of current activity in CVD and stroke prevention within general practice settings, much of which is carried out by practice nurses. The extent to which practice nurses base their activities in this area on the best available evidence has been the subject of recent research (McDonnell et al 1997). Potential benefits of evidence-based practice in primary health care include health gain and cost-effectiveness. The focus of this literature review is to identify a range of research-based activities which practice nurses might employ in the primary prevention of CVD and stroke. The review demonstrates that while the research on the effects of risk factor reduction is well established, the evidence regarding how practice nurses can best achieve these risk factor reductions is less well defined. The quality of evidence included in the review varies enormously. Some interventions are underpinned by the most rigorous form of evidence - the systematic review (Silagy et al 1996) whilst for other interventions, the evidence is undeniably weaker and sometimes applies more to other health professionals (Richmond 1986). Therefore, the range of research-based interventions identified on the basis of this review are supported by the best evidence available at the time the review was undertaken. The literature review focuses on the following themes: 9

9

The role of the practice nurse in health promotion (particularly in relation to CVD and stroke). Risk factors for CVD and stroke and the identification of the 'best evidence' which practice nurses could utilize.

This paper focuses on the role of practice nurses in CVD and stroke prevention and the evidence surrounding smoking cessation interventions by practice nurses. Other risk factors are discussed in Part II.

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M E T H O D S A N D B O U N D A R I E S OF THE REVIEW Searches were can'ied out in September to December 1995, on the following databases: Cinahl, Medline, Kings Fund, Cochrane Database of Systematic Reviews, Health Plan, BL 11. MeSH headings used to search were:

'CARDIOVASCULAR-DISEASES'/preventionand-control 'CEREBROVASCULARDIS ORDERS'/prevention-and-control 'OFFICE NURSING' 'PRIMARY CARE' 'HEALTH PROMOTION' Keywords for searching were: practice nurse, primary care nurse, and cardiovascular disease (CVD), coronary heart disease (CHD) cerebrovascular disease, stroke, cerebrovascular accident. Additional searches were also performed using keywords for individual risk factors: smoking, hypertension, cholesterol, exercise, obesity. The review was further developed using an incremental approach by examining the reference list for each paper retrieved. In addition, the following journals were handsearched for 1995:

British Journal of General Practice Quality and Health Care Journal of Clinical Nursing Practice Nurse The Lancet British Journal of Nursing European Heart Journal Journal of Public Health Medicine Hand-searching of current issues of key journals was conducted on an ongoing basis during 1996. Guidelines and policy documents relating to the prevention and management of CVD and stroke were also accessed. This included hand-searching HMSO catalogues for 1993 and 1994 and handsearching all DOH letters, reports and circulars, executive letters and guidelines from March 1993 to October 1995 held at Trent Health Authority library. Incremental review was carried out from these also. References were also located through personal contact with content area experts. Decisions on inclusion criteria for studies examining the effectiveness of practice nurses were pragmatic. The strongest evidence regarding the effectiveness of practice nurses in CVD and stroke prevention is likely to emerge from rigorously designed and conducted randomized controlled trials. However, given the practicalities of randomization of large numbers of patients or GP practices, large numbers of studies of this nature were seen as unlikely. Non-equivalent group designs with pre/ post measures and interrupted time series were therefore considered appropriate for inclusion.

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This broad search strategy yielded 140 relevant citations. A systematic approach then focused upon the identification of key features of each item including themes, boundaries, methods, findings, conclusions/ claims and methodological/theoretical critique. It should be noted that this review focused on primary care settings only and did not include nursing interventions which are hospital-based.

T H E ROLE OF P R A C T I C E N U R S E S The role of the practice nurse has been the subject of a number of descriptive studies (Atkin et al, 1993; Peter 1993; Robinson & Robinson 1993; Ross et al 1994; Hibble 1995; Jeffreys et al 1995; Mackereth 1995). These studies were carried out after the 1990 changes to the GP contract, but before the 1993 changes when health promotion bandings were introduced. They all conclude that the role is poorly defined and remarkably varied. Activities include dressings and immunizations, screening activities, disease management and health promotion duties. Non-nursing activities such as reception work, filing and administrative duties have also been shown to be part of the practice nurse role (Peter 1993; Robinson & Robinson 1993; Ross et al 1994; Hibble 1995). There is evidence to suggest that administrative duties have increased with changes in GP contracts (Hibble 1995). A more recent study by Le Touze and Calnan (1995) concentrated on the practice nurse's role in cardiovascular disease prevention, while Atkin and Lunt's qualitative study looked at the practice nurse's role and interviewed 56 nurses to complement their earlier survey (Atkin & Lunt 1995). These studies do not suggest that practice nurse roles have altered greatly in recent years.

Practice nurses and health promotion As a result of the increase in health promotion activities in general practice (brought about by the changes in GP contractual arrangements in 1990) practice nurses now spend more of their time in health promotion activities (Cant & Killoran 1992; Hibble 1995). Health promotion activities in general practice are largely carried out by practice nurses alone, or by practice nurses working with other nurses or GPs (Cant et al 1992; Calnan et al 1994; Le Touze & Calnan 1995). A local survey of five general practices identifies practice nurses, as well as GPs, as the patients' preferred health advisor (South Tyneside Patient Satisfaction Workshop 1995). Surveys have also demonstrated that practice nurses perceive themselves to be effective educators (Le Touze & Calnan 1995), specialists in health promotion (Mackereth 1995) and in some cases more enthusiastic than GPs about health promotion (Le

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Touze & Calnan 1995). In summary, practice nurses appear to be the main providers of preventive services in general practices and evidence suggests that they feel competent in this area. The activities of practice nurses in relation to cardiovascular disease and stroke prevention have been the focus of work by Cant, Killoran, Calnan and Le Touze at the University of Kent at Canterbury. This large project, commissioned by the Department of Health, comprised two surveys in 1991/92 and 1994. The surveys describe the nature of cardiovascular disease prevention in general practice, the roles of the general practitioner, district nurse, health visitor and practice nurse within this field and the impact of the 1993 health promotion programme (Calnan & Williams 1992; Cant, Killoran & Calnan 1992; Le Touze & Calnan 1995). The practice nurses in the study (948 in 1991 and 640 in 1994) were a convenience sample (one per practice). Practice nurses were shown to use a variety of interventions, including checks of blood pressure, urine, height, weight, assessment of overall risk of cardiovascular disease, advice and follow-up. However, findings are reported in insufficient detail to judge whether practice nurses are basing their interventions on the best possible evidence in this area of their practice. Furthermore, in 1994, of 640 practice nurses in the survey, only 188 (29%) indicated that their work in health promotion was monitored.

T H E E F F E C T I V E N E S S OF PRACTICE NURSES There has been little systematic evaluation of the effectiveness of practice nurses' work. Through an audit of patients' notes in 50 general practices, Steam and Sullivan (1993) demonstrated that structured care involving a practice nurse results in improved care of diabetic patients. The outcome measures used were hospital admission, measurement of glycosylated haemoglobin and the presence of cardiovascular, renal or neurological complications. In a controlled trial, Fullard et al (1987) demonstrated, by auditing the recording of risk factors in patient notes, that through the use of a systematic approach, practice nurses can effectively identify risk factors for arterial disease. The introduction of a health promotion nurse, coupled with computerassisted follow-up, has also been shown to significantly increase recording of CVD risk factors in general practices (Robson et al 1989). Le Touze and Calnan (1995) report that recording of risk factors for cardiovascular disease was higher for practice nurses than for GPs. These studies provide some evidence that practice nurses are effective in screening for risk factors for CVD and stroke. However, they provide little evidence that interventions practice nurses are making in this area are based on the best available evidence.

Two recent randomized controlled trials: OXCHECK (Imperial Cancer Research Fund OXCHECK Study Group 1995) and the British Family Heart Study (British Family Heart Study Group 1994) BFHS, sought to evaluate the effectiveness and cost-effectiveness of health checks, lifestyle interventions and follow-up undertaken by nurses in primary care settings, in relation to cardiovascular risk factors. The OXCHECK study (Imperial Cancer Research Fund OXCHECK Study Group 1995) evaluated the effectiveness of health checks on serum cholesterol concentration, blood pressure, body mass index, smoking prevalence and selfreported dietary, exercise and alcohol habits over a 3-year period. Subjects were 11 090 patients aged 35--64 years (80.3% of potential participants) from five general practices in Bedfordshire, who were randomly allocated to control or intervention groups. Nurses providing the intervention were trained in the identification and modification of risk factors and in the use of a communication model said to emphasize the importance of responding to the patients' concerns and supportive follow-up. No differences were found between intervention and control groups in smoking prevalence or alcohol use and only small differences in blood pressure, which may be attributable to accommodation in measurement. However, mean serum cholesterol was 3.1% lower in the intervention group and self-reported saturated fat intake was also significantly reduced. The British Family Heart Study (British Family Heart Study Group 1994) involved 13 matched pairs of general practices in 13 towns in Britain. Subjects were 12 472 men and their partners. The two practices in each town were randomly assigned to either intervention or comparison groups. The intervention was conducted by research nurses trained in measurement of risk factors, follow-up and client-centred lifestyle counselling with families. After 1 year, the pairs of practices were compared for differences in total Dundee risk score and smoking, weight, blood pressure, blood cholesterol and glucose concentration. A 16% reduction in risk score was found for men in the intervention group, with a similar reduction in women. A reduction in blood pressure accounted for almost half the reduction in risk, with reductions in smoking and cholesterol concentration accounting for the remainder. However, the authors suggest that the latter two findings are likely to be due to follow-up bias and an accommodation effect, respectively. These two studies demonstrate that measurable, if modest, health gains - particularly in relation to blood pressure and cholesterol levels - can be achieved by the systematic provision of lifestyle assessment, counselling and follow-up, provided by nurses in primary care settings. In terms of impact on mortality rates, this equates to a 12% reduction in CVD deaths and 17% fewer stroke deaths

Prevention of cardiovasculardiseaseand stroke

(Pharoah & Sanderson 1995). However, questions have been raised regarding the cost-effectiveness of such programmes. The BFHS group (British Family Heart Study Group 1994) for example, suggest that for a practice with a list size of 1 000 men aged between 40-59 years, four nurses would need to be employed full-time, over an 18-month period, to provide the level of intervention offered within the study. Recent work suggests that the net costs per life-year of these programmes are likely to depend heavily on the duration of the effect (Wonderling et al 1996). For example, OXCHECK is likely to be cost-effective if the effect lasts at least 5 years while the effects must last at least 10 years to justify the extra costs of the British Family Heart Study (Wonderling et al 1996). Other studies (Viatiainen et al 1994) have demonstrated similar levels of risk factor modification at 1 and 3 years post-intervention. However, after 20 years, the reduction in CVD-related mortality and morbidity has risen to 40%. Therefore, judgements regarding the costeffectiveness of the OXCHECK and BFHS programmes may well be premature. A number of criticisms have been made of these studies; for example, the questionable validity of using the same criteria for the outcomes of health promotion as for studies such as drug trials (McPherson 1994). Cowley (1995) criticizes the overall approach as a 'paternalistic' health promotion strategy which has already been 'tried and found wanting'. Finally, Mullen et al (1992) and Cowley (1995) note that little detail is given as to the exact nature of the interventions. Hence, there is no opportunity to evaluate whether nursing interventions were based upon the best available knowledge. While BFHS and OXCHECK have generated debate about health promotion in this area, they have failed to identify specific interventions, with a strong research base, which nurses in general practice could routinely employ to reduce CVD and stroke risk in their practice population.

RISK FACTORS IN C A R D I O V A S C U L A R DISEASE A N D STROKE A review of research-based reports, guidelines and manuals in relation to the prevention of CVD and stroke reveals consensus regarding major preventable risk factors, specifically smoking, hypertension and raised plasma cholesterol (DOH 1993a; DOH 1993b; Trent 1993). However, invariably these reports highlight additional contributory factors, including inadequate exercise (DOH 1993b); being overweight, lack of physical activity and inappropriate diet (Trent 1993). The effectiveness of general health checks has already been considered. The following section addresses smoking one of the major preventable risk factors. A subsequent paper will consider the

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effectiveness of interventions aimed at reducing other risk factors - specifically raised blood cholesterol, raised blood pressure and lack of exercise.

Smoking and C V D risk Cigarette smoking is a well-recognised, doserelated risk factor for CVD (Faculty of Public Health Medicine 1994) and is estimated to account for up to 18% of CVD deaths. The contribution of smoking to CVD deaths before the age of 65 is higher still (Trent Health 1993). Many studies have demonstrated the extent of the increased risk. The Framingham Study (Dawber 1980) and the British Regional Heart Study (Shaper 1988) indicate that smoking is associated with a 2-3 times increase in CVD risk compared with nonsmokers. Smoking also contributes to overall CVD risk through interaction with other risk factors such as raised BP and cholesterol (Doll 1976; Shaper 1988). When these other risk factors are present, then the risk of CVD mortality can be as much as 8 times that of a non-smoker (Doll 1976).

Smoking cessation and C V D risk Reducing the prevalence of smoking will have more impact on CVD than modification of any other risk factor (Trent Health 1993; Langham et al 1995). Many longitudinal studies of smoking cessation have demonstrated a marked reduction in CVD and stroke risk among ex-smokers. In middle-aged men, smoking cessation is associated with a decreased risk for stroke, with the benefit seen within 5 years of giving up (Wannamethee et al 1995). Whereas original estimates of smoking cessation benefits were a 50% reduction in CVD risk at 1 year (US Department of Health and Human Services 1990), data from the British Regional Heart Study (Shaper 1988) indicate that the real value of the reduction may be somewhat lower. After 1 year, risk declines more slowly. It has been estimated that a reduction in smoking prevalence of one-third could reduce CVD deaths by 6-8% over a period of years (Trent Health 1993). If smoking were eradicated, it could reduce CVD by 40% (Trent Health 1993).

Anti-smoking interventions in primary care GPs and smoking cessation Brief advice There is evidence from a number of randomized controlled trials to indicate that repeated, brief advice from GPs, both verbal and written, is effective in helping people to stop smoking (Russell et al 1979; Jamrozik et al 1984; Richmond et al 1986). However, definite conclusions about the relative effectiveness of different interventions are made difficult by methodological difi~rences between

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studies (Sanders 1992). The overall conclusion of this and other reviews of the literature is that brief advice from GPs during routine consultations helps a small but significant number of smokers to stop for at least a year. Reported smoking cessation rates for intervention and control groups: 9 9

at 1 year follow-up, range 2.9-13.7% (control); 5.0-16.7% (intervention); at long-term follow-up, range 0.3-4% (control); 1.0-3.3% (intervention).

Although overall rates are low, Sanders points out that the effects are magnified by the large number of GP consultations (Sanders 1992). It has been estimated that if all GPs gave this advice and achieved a 5% quit rate, this would be equivalent to half a million ex-smokers per year in the UK (Russell et al 1979). Anti-smoking advice during routine consultations has been demonstrated to be at least as cost-effective as other practices such as the treatment of hypercholesterolaemia or mild to moderate hypertension (Cummings et al 1989). Other studies have shown that the effectiveness of brief advice can be increased by a variety of strategies, such as follow-up appointments (Richmond & Webster 1985; Richmond & Heather 1990; Wilson et al 1990; Ockene et al 1991), smokers clinics (Russell et al 1988), the use of simple protocols (Glynn & Manley 1989; Glynn et al 1990a; Glynn et al 1990b) and the use of carbon monoxide monitors (Jarnrozik et al 1984; Richmond et al 1986). A recent systematic review of the effectiveness of physician advice to aid smoking cessation (Silagy & Ketteridge 1996) concludes that brief advice does have a small effect on smoking cessation, with additional strategies including the use of self-help manuals, or methods which demonstrate a pathophysiological effect of smoking (such as carbon monoxide monitors) proving marginally more effective. These marginal benefits are more likely to be realized for individual, motivated smokers, and therefore these additional strategies may not be justified as routine interventions for all smokers.

Brief advice combined with nicotine substitution A number of trials have evaluated the effectiveness of nicotine replacement therapy as an aid to smoking cessation. Sanders (1992) cites three reviews in this area: Lam et al (1987), Gouflay and McNeil (1990), and Hall et al (1990). In smoking clinics, where smokers are motivated to stop and receive intensive support and follow-up, l-year cessation rates of 31-63% have been achieved, compared to 14 ,15% for placebo control groups. In primary care settings, where subjects may not be motivated to quit and compliance may be lower, success rates have not been as high. Meta-analysis of trials using nicotine gum indicate success rates of 9% compared to 5% for placebo controls indicating that gum is

only slightly more effective than brief advice alone (Lam et al 1987). However, a more recent metaanalysis demonstrated quit rates of 19% with nicotine gum compared to 10% in the controls (Silagy et al 1996). Other trials have demonstrated improved cessation rates with nicotine gum in primary care settings, through a variety of strategies: 9 9

9

selection of smokers who are already motivated to stop; selection of smokers who are heavily dependent on nicotine rather than the social/psychological effects of smoking; addition of other interventions such as setting a quit date or follow-up advice and support.

Nicotine substitution in the form of transdermal skin patches offers potential advantages over nicotine gum, since the use of gum requires considerable advice in order to obtain optimal benefits. In a study using patches in a young undergraduate population, 3-month cessation rates of 36% compared to 22% in the placebo group have been demonstrated (Abelin et al 1989). Cessation rates dropped considerably after 9 months, although they remained 1.5 times higher than the control group. More recently, the Imperial Cancer Research Fund General Practice Research Group (1993) achieved a 20% cessation rate using nicotine patches. In the United States, where transdermal nicotine has become one of the most frequently prescribed medications, a doubleblind randomized controlled trial combining patches with follow-up support demonstrated significantly higher cessation rates in the active patch group at 8 weeks (46% vs 20%) and 1 year (27.5% vs 14.2%) (Hurt et al 1994). A recent meta-analysis yielded quit rates of 15.5% amongst smokers using nicotine patches compared to 10% of controls (Silagy et al 1996), with increased effectiveness for smokers who have high levels of nicotine dependency and are motivated to quit. In summary, there is convincing evidence demonstrating that nicotine gum offers increased smoking cessation rates over brief advice alone in primary care settings, particularly for motivated smokers with high levels of nicotine dependency, when combined with support and follow up. Recent evidence suggests that similar cessation rates are achievable with nicotine patches (Silagy et al 1996).

Practice nurses and smoking cessation The research in this area is more equivocal, not least because primary health care staff, other than doctors, have received little attention in this area (Sanders 1992). The information available is frequently anecdotal in nature, or lacks the rigour of a randomized controlled trial. Examples of work which have evaluated nursing interventions in smoking cessation positively include Macleod-Clark et al (1990). This small study found that using a framework based on a

Prevention of cardiovascular disease and stroke

health belief model and the nursing process, community nurses can be effective in helping patients to stop smoking (17% cessation rate at 1 year post intervention). Hollis et al (1993) conducted a randomized controlled trial to determine the impact of nurse-assisted counselling for smokers in primary care settings in the U S A . They concluded that the involvement of nurses relieved pressure on physicians and significantly increased cessation rates when compared to brief physicians' advice alone (7% :3.4%). However, nurses in the study received intensive training in smoking cessation techniques. Other studies have demonstrated the positive benefits of follow-up care and support by nurses, following an initial suggestion to stop smoking from a GP (Sanders et al 1989; British Thoracic Society 1990; Vetter & Ford 1990). This evidence is not supported by a number of studies which fail to demonstrate that nurses have a significant impact on smoking cessation (Sanders et al 1989; Sanders & Marzillier 1990; Rice et al 1994). The literature suggests that many practice nurses may not be motivated to be involved in such work, or perceive they do not have the necessary skills and knowledge to be effective (Macleod-Clark et al 1985, cited in Macleod-Clark et al 1990; Sanders et al 1986; Sanders & Marzillier 1990). Several authors have reported on the positive effects of education on the motivation and confidence of staff in this area (Macleod-Clark et al 1990; Sanders & Marzillier 1990; Silagy et al 1994). As yet, there is little data to evaluate any direct effects of this in practice.

Summary Health professionals can have a significant impact on smoking cessation rates. Although the evidence is equivocal and further research is indicated, there is evidence to suggest that practice nurses can be effective, particularly when working in partnership with GPs, but also when working independently, if properly prepared in smoking cessation techniques. There is no clear indication from the literature regarding which (if any) smoking cessation intervention/framework is better than any other. However, it is clear that repeated advice for people to stop smoking is to be advocated, whether this is as part of an intensive programme of support, or of brief opportunistic interaction. Intensive programmes including such activities as: providing leaflets on smoking; negotiating dates for stopping; giving feedback on patients' exhaled carbon monoxide levels; and the offer (or threat) of follow-up would all seem to have positive potential. It is also apparent that nicotine replacement therapy is effective as part of a smoking cessation strategy, especially if the patient is nicotine dependent and motivated to stop.

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Box I Research-based activities for nursing practice in relation to smoking cessation Clear, repeated advice to stop smoking supported by a range of techniques: provision of leaflets 9 negotiating dates for stopping 9 givingpatients feedback on exhaled carbon monoxide

9

9 9

levels patient follow-up nicotine replacement therapy (particularly in those motivated to stop)

Nurses in general practice should therefore take every opportunity to convey the 'quit smoking' message, supported by a range of smoking cessation techniques, whilst offering nicotine replacement as an extra mechanism for assisting people to stop. Box 1 summarizes the research-based indicators for nursing practice in primary care in relation to smoking cessation. The second paper in this series will address the effectiveness of interventions aimed at reducing a number of other risk factors for C V D and stroke - raised blood cholesterol, hypertension and lack of exercise.

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Clinical Effectiveness in Nursing

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